Published Jun 21, 2009
Hi i am puzzled as why we have to take respirations last on an adult while taking vitals?
?? Never heard of this. I'd do this first as you don't even have to touch/wake someone to do it.
Often if a Pt is aware that you're counting, they'll subconsciously change rate/pattern.
which is why you don't tell them that you're counting their respirations
After taking the patient's pulse, you can act like you are still taking the pulse but actually count the respirations. This way the patient doesn't know your taking his/her respirations (like the other response said, they will change their rate if they know they are being watched.)
Forever Sunshine, ASN, RN
You are supposed to do it while pretending to take their pulse. I'll do it while talking to them if they are alert and oriented. During my med-surg rotation the hospital had the little tempadot strips. While we were waiting for the tempadot I'd take my pts resps. She was nonverbal and her orientation was unknown so I could do that with no problem.
If I notice my patients resps are normal I will only count for 30 seconds. If I see they are labored or uneven, I'll count for the full minute.
Never tell them that you are taking their resps.
I think the idea is, as stated, not to make it obvious that you're counting their resps, as they make consciously or unconsciously change their respiration patterns. The best hint is to count their pulse, then, when you've managed to get that figure, keep your hand on their wrist, though loosen your grip a little so you aren't distracted by the pulse, and count their resps. That way it looks like you're still taking their pulse and the patient will be none the wiser. You should get an accurate figure that way.
Hello? She's not asking how to take respirations!!
It seems odd that you were told to take respirations last. At our school, we were not given a specific order for taking vital signs.
Well i follow systamatic ABCDE (PRIMARY SURVEY) approach when assessing my patients' prioritys' so breathing would come after airway .
yes i do agree with the rest that after you take the patient's pulse, you can act like you are still taking the pulse but actually count the respirations. This way the patient doesn't know your taking his/her respirations (like the other response said, they will change their rate if they know they are being watched.)
ABCDE Primary Survey
Assume C-spine inujury
immobilize c-spine with collar or sand bags
1) Assess ability to speak
4) Ability to breathe
6) Noisy breathing
7) Respiratory distress
8) Extra sounds
10) Choking sign
11) Look for causes of airway obstruction
12) Look inside mouth
13) Look for facial and neck trauma
Jaw thrust to open airway. Suction secretions which may be obstructing airway.
If airway compromised, secure with NP airway.
Continously reassess airway.
Assess respiratory rate
O2 saturation, pulse oxymetry
Mental status and for agitation
Movement of chest (flail segments)
Accessory muscle use
Sounds of airway obstruction, such as stridor
Air entry, is it symmetrical
Trachea (for shift)
Chest wall for crepitus
Sucking chest wounds
If breathing is compromised, give nasal prongs, venture mask, bag-valve mask and ventilate.
Assess pulse rate and quality (strength)
Obtain blood pressure and pulse pressure
Assess capillary refill
Ask about urinary output estimation
Stop any major external bleeding
Insert 2 peripheral large bore IVs
If difficult, obtain a central IV
Assess LOC by avpu:
Responds to Verbal stimuli
Responds to pain
Assess pupils for:
Expose patient entirely
Keep patient warm
General - ask for vitals q5-15 minutes
Do an EKG, FAST (U/S abdomen)
Monitors (BP, pulse oximetry)
Order: CBC, lytes, BUN, Cr, Glucose, Coags., Cross and Type,
hCG, Tox screen, LFTs, Amylase
Really? Last? That's the first thing I look at while I'm assessing LOC.
By using the site, you agree with our Policies. X