Inaccurate respiratory rates

[MattNurse]

Do you trust the respiratory rates the CNA's chart?

I notice that some of the CNA's on my unit always chart the same number for respiratory rate. The other day I had 5 patients and all had vitals Q4 and each time their respiratory rate was 18, for 15 sets of vitals that seems astonishing and improbable. When I was doing my assessment some had RR of 11 to 25. It frustrates me since respiratory rate will be one of the first things to indicate a problem.

[hiddencatRN, BSN, RN]

Depends. Most of my coworkers, yes. But I think a lot of people "eyeball" it, which can be problematic. A patient can be breathing really fast but appearing to be at a "comfortable" rate for their age. I had a coworker help me with initial vitals on a patient once, and this kid was charted as a respiratory rate of 24. About half an hour later, I noticed that he appeared to be breathing really quickly, so I recounted and got 40. "That can't be right" I thought. So I counted again, and again, and again, and each time it was right around 40. So now I'm freaking out because I think my patient has had a sudden change in status, to go from a comfortable if a little high rate to a seriously tachypneic rate. I start doing Q15 min vitals on him to make sure it wasn't a fluke, had the doctor over at the bedside, etc. Patient got a chest x-ray and ended up having raging pneumonia. After repeated vitals, I realized that the original 24 rr was likely eyeballed. If I hadn't noted the fast-appearing breathing, this patient's diagnosis and treatment would have been delayed, particularly since he had no other respiratory symptoms, was afebrile, etc. Luckily (?) the patient had a lot of other stuff going on, so it didn't change his assigned acuity, but what if it had?

[hiddencatRN, BSN, RN]

I usually count them when the bp pump is going or hold a wrist, peeking at my watch.... but really counting chest expansions. People generally stop talking when I do those things.

This is what I do. Pretend I'm taking a pulse. We were taught that in nursing school and I love that trick.

[kool-aide, RN]

I was taught in my CNA class to count respirations for 15 seconds and multiply by 4. So, all my RRs are going to be multiples of 4…

[RNewbie]

Most CNAs that I work with just "guestimate" the resp rate. I always count my own rate. Sometimes when they report the vitals off to me and I'm almost sure that it is not correct I usually say something like "Can you make sure to count Mr. Smith's resp rate for a full minute to get an accurate rate because his resp have been irregular." That usually lets them know to take RR more seriously.

[prinsessa]

I had one tech put all RRs in as 22. I think 22 is even a little high...and for everyone to be breathing that fast.

[Hygiene Queen]

I know that some techs don't know that counting for 15 or 30 seconds only works if the pattern is regular.

The same is true for the heart rate.

I also know that some nurses would rather write the tech off as stupid or useless than teach them the right way to do things and the why behind it.

But in spite of everything, I can't seem to get certain techs and BHA's to count resps!

I give plenty of CNS depressants and I do worry about my patients' breathing... funnily enough.

[NO50FRANNY]

I almost NEVER trust any documented RR. The relaxed 18 year old with resps of 18????? I just counted my own and and it's 12. I see it all the time- ambulance crews do it too and I've had a couple recently where I have asked directly, and the response is "oh, 24 or thereabouts, I count it at triage and it's close to fourty, the difference between a resus bay and an acute bay. I call it radar observations.... My trick (so they don't change breathing pattern) is to tell some silly story and watch out of the corner of my eye doing the radial, usually works. If someone has documented something unlikely I ask the person directly "was this patient distressed when you counted this?", usually it's done properly after that.

[Despareux]

I never trust a documented RR unless it's been done by me; I've seen way too many 18's and 20's that were far from accurate. Personally, I think RR's should only be done by RN's.

[GLORIAmunchkin72]

When a resident is agitated it can be hard to get an accurate count. It's best then to get a second opinion.

[BelgianRN]

If others do my vital signs I'm usually double checking abnormal values before taking action. In Belgium we have no CNAs or something related so generally if I'm not doing my own vitals it is a student nurse that takes them and based on my assessment of his/her qualities as a student nurse I'm more or less inclined to believe their vital signs.

Somewhat related. Had a nurse come to me with an EKG the other day and she asked me to interpret it. It had and odd R-wave progression in the anterior leads and I suspected V2 and V3 had switched places. So I ask her who took the EKG and she tells me it was the student nurse. The student nurse got mad when I asked her if she was sure of her lead placement saying we expect the impossible from them and they have to know everything. So I redo the EKG and it shows normal R-wave progression now so my assumpion was valid. I was still chastised a day later for making a "potential new colleague" cry and I apparently should have handled it with more tact.

I've learned always double check things that don't add up as two eyes see more than one.

I still remember years ago someone switched the pressure transducers of CVP and ABP on a fresh post CABG patient just arriving in the neighbouring ICU. And nobody bothered checking the set up of the monitor but assumed PEA and gave 1mg epi iv it ended badly for the patient, nurse and MD all because there was no double check.

[healthstar, BSN, RN]

Wow! Big deal! Respirations are so easy to count, it takes less than a minute, or maybe less than 30 seconds. There is only one way to prove that the assistant knows how to count, or is doing her job......the nurse and the assistant both have to count at the same time........otherwise you will make assumptions. The patients RR might be 20 now, and less than 6 within 2 minutes.......if you take BP,pulse, RR the first 5 minutes, and wait 2 minutes and retake I guarantee you it will not be the same :) ......btw I have done millions of VS and I have bound that the mode for resp are : 16,18,20:)

[canned_bread]

Oh what a wonderful question! I asked a student nurse to do obs on a patient on PCA morphine. When she came out I asked her if the obs were in acceptable limits, she responded yes. I trusted. Minutes later I entered pt room, patient was cyanosed and resps WAY DOWN, patient barely conscious. After the MET call was over I asked to see students obs, somehow they were all in acceptable limits (we are talking BP EXACTLY 120/80 etc, RR EXACTLY 20 etc). Student stated patient was very much conscious and she had no concerns. I couldn't believe the student, had to report to her facilitator although I felt bad. I think it's a real lesson that you just can't trust anyone but yourself. Respiratory can be the first thing that tells you something is up. If the BP or pulse is not good, that seems to often be the 2nd indication something is wrong.