Respirations

NeoNurseTX, RN · Jun 21, 2009

?? Never heard of this. I'd do this first as you don't even have to touch/wake someone to do it.

PageRespiratory! · Jun 21, 2009

Often if a Pt is aware that you're counting, they'll subconsciously change rate/pattern.

shrimpchips, LPN · Jun 22, 2009

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

AH_AH_86 · Jun 22, 2009

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 · Jun 23, 2009

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.

rachelgeorgina · Jun 23, 2009

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.

zsbaby · Jun 24, 2009

Hello? She's not asking how to take respirations!!

2bnurseplease · Jul 4, 2009

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.

chrissy student · Jul 6, 2009

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

Airway Assessment

1) Assess ability to speak

2) Dysphonia

3) LOC

4) Ability to breathe

5) Apnea

6) Noisy breathing

7) Respiratory distress

8) Extra sounds

9) Cyanosis

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.

Breathing Assessment

Assess respiratory rate

Would obtain:

O2 saturation, pulse oxymetry

ABG

CXR

Look at:

Mental status and for agitation

Movement of chest (flail segments)

Accessory muscle use

Colour (cyanosis)

Listen for:

Sounds of airway obstruction, such as stridor

Breath sounds

Air entry, is it symmetrical

Air escaping

Palpate:

Trachea (for shift)

Chest wall for crepitus

Subcutaneous emphysema

Flail segments

Sucking chest wounds

Chest percussion

If breathing is compromised, give nasal prongs, venture mask, bag-valve mask and ventilate.

Circulation Assessment:

Assess pulse rate and quality (strength)

Obtain blood pressure and pulse pressure

Assess capillary refill

Skin colour

Ask about urinary output estimation

Stop any major external bleeding

Insert 2 peripheral large bore IVs

If difficult, obtain a central IV

Disability Assessment

Assess LOC by avpu:

Alert

Responds to Verbal stimuli

Responds to pain

Is Unresponsive

Assess pupils for:

Size

Reactivity

Extremity movement

Exposure Assessment

Expose patient entirely

Keep patient warm

Orders

General - ask for vitals q5-15 minutes

Do an EKG, FAST (U/S abdomen)

Monitors (BP, pulse oximetry)

Foley catheter

NG tube

Order: CBC, lytes, BUN, Cr, Glucose, Coags., Cross and Type,

hCG, Tox screen, LFTs, Amylase

http://www.medical-examination.org/abc-primary-survey/

ZanatuBelmont · Jul 9, 2009

Hi i am puzzled as why we have to take respirations last on an adult while taking vitals?

Really? Last? That's the first thing I look at while I'm assessing LOC.