Counting Respirations

emptyboxcars · Mar 25, 2012

these are all going to get you resting respiratory rate, sure, but be sure you are also able to count accurately when the patient is up and walking, in pain, etc.

do not fall into the trap of the ward with synchronous ventilation . this is when the cna takes all the vital signs and everyone is, magically, breathing at 20 (or maybe in your establishment it's 18). this is a classic right out of the wonderful little book called "ritualistic practices in nursing," and is shorthand for "respirations normal and unlabored." you will also see on the patient's graphic chart that resps are remarkably stable over 24 hours.
once when i was a nursing aide i floated to a floor where the "normal" was not 18 but 20. i didn't know that, so all my patients were at 18. all hell broke loose. it was really ludicrous, and made me start thinking about why we didn't really count and chart what we found. other aides told me it was just because it took too long. really, a minute is too long?

wow. i can't believe people actually do that. that's scary.

emptyboxcars · Mar 25, 2012

Thanks for the feedback everyone. I have counted respirations while the patient is sleeping as well. That works great. I also like the idea of just telling the patient I'm going to take their pulse for a full minute so they already expect that. I will continue to practice counting respirations while doing vitals. I think it's one of those things that just takes practice. Everyone is different and strong/weak in different areas. Thanks again for the helpful comments.

BrandonLPN, LPN · Mar 25, 2012

Just because I like to stir thing up a little ( :) ) I'm going to play devil's advocate a bit here.....

When I was an aide at the hospital I routinely had to get q4hr vs on 20 to 30 pts. And I gotta say anyone who says they stop and count

respers for every single pt is probably telling a fib. After you spend almost 40 hrs a week checking vs you really can look a someone for few seconds and know their rate.

Now before everyone gets in an

uproar, I should say I was regarded by the nurses on my floor as being known to get the most accurate vitals. Many times RNs thanked me because I brought to their attention their pt on an epidural's respers were 10, not 18 as all the other

aides had been charting. I also got compliments for noting unconscious pt's respers were 32 (not "magic number" 18) and this helped the nurse determine to give pain meds. I also always rechecked BP manualluy if the machine gave out

of normal range reading. And many a pt was placed on remote telemetry because I noticed the pulse on the pulseox was jumping around and when I felt a radial pulse it was clearly irregular.

These days, as a LPN in LTC, I prefer to get my own vs rather than having the CNAs get them. I'm amazed at how little they know compared to what we aides in the hospital knew. I've seen temps of 94.8 and BPs of 70/30 be treated and charted as if they were normal! So what's my point? My point is of *course* always charting magic number 18 (or whatever) is wrong. But I can also say I can "eyeball" most people's respers. If they look out of range, then I stop and count. Every nurse has their own strengths and their own way of doing things. And the "textbook" way is not always feasible. I'm still a good nurse even if I look at one of my residents and determine their RR is 14 or 16 just by looking at them!

gallatea · Mar 25, 2012

Moral of the story should also be, treat the whole pt., not just the number and not just the machine. One person's normal as stated above is not everyone's normal. And if you are worried about having difficulty getting a number or feel you missed a breath - look at them as a whole. What other S/S do they have that prove they are having resp. difficulty (RR is just one assessment tool)? If all else is stable, and all other phys. exam results are good regarding oxygenation and perfusion, don't freak yourself out about getting 13, when you think it should be 14. It's going to vary from minute to minute to some degree. And ask for help if you are having trouble or truly worried. Every pt. doesn't need his resp. counted for a full minute. Check your hospital's policies and protocol, it can vary by dx, floor, etc.. And that is truly what you should be going by, not what we say.

QuarterLife88, MSN, RN, NP · Mar 25, 2012

if you can't chew gum and walk, you're in trouble in the real world..counting respirations should not be this difficult that we need a page dedicated to it.

rude and uncalled for.

nurseprnRN, BSN, RN · Mar 25, 2012

it is possible for the sensitivity to be set too low on a vent, so a patient's inspiratory effort is not enough to trigger a cycle (rude, huh?). it is also possible (and you probably know this, so it's for vent-naive folks) for a vent to be set to deliver a set number of breaths but to allow the patient to breathe fully on his/her own in between cycles. ideally, the ventilator should have enough brains to watch the patient's own resps and when it's about time for a mechanical cycle to coordinate it with the next naturally-occurring inspiratory effort, avoiding the cycle when the patient's chest is already full from a spontaneous breath. there also variations on these-- pressure support mode is one add-on that supports spontaneous respirations, and can be backed up with mechanical cycles.

however, the indicator panel ought to give you the accurate count no matter what.

i wonder if your patient's efforts were unrewarded by actual air, and that would really make him struggle.

Alikatz · Mar 25, 2012

"grntea - if you want to cause a stir some peaceable afternoon, count actual resting resps (which are often in the 12-14 range, or less) and chart them. people get into a major tizzy. you can really make them crazy if you report resps of 10, because that seems to be the level when everyone panics about opioids."

haha that happened to me once during clinical a few months ago! i counted respiration's on one patient and it happened to be 10 at rest. the pca couldn't believe it even after i took it for a second time and still came up with 10 lol. i let the primary rn know and so did the pca. i took it for a third time and so did the rn, who also got...drum roll...10. i of course charted my findings. it's just amazing how they get their hair tied in a bunch if it's not 18-20! even while working as a pca at the same facility years ago well before getting into nursing i noticed other aides who wouldn't even truly count any respiration's and would simply put down the magical 18-20 number because those particular ones just didn't want to take the time out to actually count. it would annoy me a little only because i would take time out to count so i had an accurate respiratory rate charted.

theantichick · Mar 26, 2012

Wow. I can't believe people actually do that. That's scary.

I can. I've done 2 semesters on med-surg now, and on my first semester the hospital I was at, the techs actually counted respirations and were conscientious about getting accurate vitals. At the second hospital for my 2nd med-surg rotation, I was amazed to find out that every patient on the floor, no matter the time of day or which PCT recorded it, had respirations of 18. I mentioned it to my nursing instructor, and she was appalled, but from what I could see nothing ever came of it.

I don't think every tech does this, but I can tell you when I become an RN, I'll be double checking vitals behind every tech I work with until I learn who I can trust and not.

brillohead, ADN, RN · Mar 26, 2012

My preceptor once charted a complete bed bath, with back care, foot care, oral care, and linen change. What had she actually done in the room? She gave him his PO meds. :rolleyes:

After she left the room I changed his BM diaper, but his sister was visiting so I didn't do his bath at that time (I did assess his skin on his back/backside while I had him turned), nor did I come out of the room with dirty linens. She also didn't chart that "the nursing student" performed those things -- she charted that she personally did the care.

maccheese · Mar 27, 2012

We have to count for a full minute. In efforts to not lose concentration, breathe yourself, at the same rate as your patient and count.

SENSUALBLISSINFL, BSN, RN · Apr 7, 2012

i agree with nguyency77, this forum is to help each other with any question we might have, however minor some may think it is.

i am in my last semester and i had issues with this as well in the beginning of the program, and the distractions do not help. so what has been posted about counting the respiration rate after auscultating the lungs is very helpful, i count 30 seconds, if it is not regular then a full minute. is always better to be sure and be as accurate as you can be. i also agree, chart what you find, do not make it up.

if we; as nurses or student nurses, help each other and back each other as a group, it would be so much easier in the floor as well as in the school. allnurses,com is about helping each other. good luck with our suggestions.

grpman · Apr 8, 2012

these are all going to get you resting respiratory rate, sure, but be sure you are also able to count accurately when the patient is up and walking, in pain, etc.

do not fall into the trap of the ward with synchronous ventilation . this is when the cna takes all the vital signs and everyone is, magically, breathing at 20 (or maybe in your establishment it's 18). this is a classic right out of the wonderful little book called "ritualistic practices in nursing," and is shorthand for "respirations normal and unlabored." you will also see on the patient's graphic chart that resps are remarkably stable over 24 hours.
once when i was a nursing aide i floated to a floor where the "normal" was not 18 but 20. i didn't know that, so all my patients were at 18. all hell broke loose. it was really ludicrous, and made me start thinking about why we didn't really count and chart what we found. other aides told me it was just because it took too long. really, a minute is too long?

think 20 resps per minute is ok? fine. take out your watch and make yourself breathe every three seconds for a full minute. fingers and toes tingly yet? can you say, "respiratory alkalosis"? people who are really breathing that fast are in trouble, generally.

if you want to cause a stir some peaceable afternoon, count actual resting resps (which are often in the 12-14 range, or less) and chart them. people get into a major tizzy. you can really make them crazy if you report resps of 10, because that seems to be the level when everyone panics about opioids. i am here to tell you that my perfectly healthy dh, age >65, has a resting resp rate of around 10 all the time. when i do my meditation, i count slow fifty breaths and then check the clock for how long it takes me. it's usually between 10 and 12 minutes, so that's about 4-5 bpm, and i am no model of physical fitness and do not pass out at this rate.
moral of the story: do the right thing. really count them. teach the aides to really count them.

just wanted to say you often help us newbies with your insight. lol...i think of what you said all the time as i see the person has magically stayed consistent at 20 respirations for the last 3 days.