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Measuring Respiratory Rate (102.101)

Measuring Respiratory Rate (102.101) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Patient Assessment

102.101



UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: MEASURING RESPIRATORY RATE

Effective Date: October, 2012 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed


PURPOSE: To provide guidelines for measurement of respiratory rate for patients at the University of
Wisconsin Medical Foundation (UWMF) or Department of Family Medicine (DFM) clinics.

DEFINITIONS:
Respiration involves ventilation (the movement of gases in and out of the lungs), diffusion (the movement of
oxygen and carbon dioxide between the alveoli and the red blood cells), and perfusion (the distribution of red
blood cells to and from the pulmonary capillaries).

Four measures of respiration – rate, rhythm, depth, and sound – reflect the body’s metabolic state, diaphragm
and chest muscle condition, and airway patency.

Respiratory rate is recorded as the number of cycles (one full inspiration and expiration) per minute.
Respiratory rate varies with age and is affected by many factors, such as, exercise, smoking, anxiety, acute pain,
illness, medications, and neurological injury.














Grunting - a sound that can be heard each time the person exhales. This grunting is the body's way of trying to
keep air in the lungs so they will stay open.
Nasal flaring- the nares spread open while breathing and may indicate that a person is having to work harder to
breathe.
Retractions –due to reduced air pressure inside the chest. This can happen if the upper airway (trachea) or small
airways of the lungs (bronchioles) become partially blocked. Retractions can be intercostal (the muscles
between the ribs are sucked inward, between the ribs, when you breathe) or they can be sternal or substernal
(the breastbone or chest under the breastbone retracts in toward the chest with breathing).
Age (yr) Respiratory Rate
(breaths/min)
Neonate/infant (<1y) 30-60
Toddlers (2-5y) 20-40
School age (6-15y) 15-30
Adult (>15 y) 12-20



POLICY: The clinical staff will utilize the following guidelines to properly measure respiratory rates for
UWMF and DFM patients.

SUPPLIES: Provider’s order, patient’s record, watch or other timing device

PROCEDURE:
1. Check provider’s order and clarify any inconsistencies.

2. Wash hands and gather equipment as necessary.

3. Introduce yourself and identify the patient. Include patient’s full name and date of birth.

4. Position patient and yourself so that the patient’s chest is visible.

NOTE: If necessary, remove exam gown/clothing or drapes.

NOTE: If necessary, place patient’s arm in relaxed position across the abdomen or lower chest, or place
your hand directly over the patient’s upper abdomen.

NOTE: A similar position is frequently used when assessing pulse rate. Respirations can be counted
immediately after obtaining pulse rate. When done this way, the patient does not know you are counting
respirations and therefore cannot alter their breathing.

5. Count respirations by observing the rise and fall of the patient’s chest as he/she breathes.

6. Count respirations for 30 seconds and multiply by 2 if respirations are regular.
NOTE: If respirations are irregular, count respirations for 60 seconds to account for variations in rate and
pattern.

7. As you count respirations, be alert for any abnormal chest movements (retractions, heaving), presence of
abnormal sounds (wheezing, rales, rhoncii, grunting) or lack of breath sounds, use of accessory muscles,
anxious facial expressions, or flaring of nostrils.

8. Notify provider if respiratory rate, rhythm, depth, or sound is abnormal.

9. Documentation in Vital Signs section of patient’s electronic chart
Enter respiratory rate in ‘respirations’ field
Utilize ‘comment entry’ to identify any abnormality in rhythm, depth, and sound

PEDIATRIC CONSIDERATIONS
When listening to breath sounds in children with croup, also observe for sternal, substernal, or
intercostal retractions
In infants, an expiratory grunting sound indicates imminent respiratory distress
A child’s respiratory rate may double in response to exercise, illness, or emotion.


WRITTEN BY: Carol Decker, RN, MSN, Clinical Staff Educator

REVIEWED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator





REFERENCES:
Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO:
Mosby Elsevier.

AUTHORIZED BY: Richard Welnick, MD, Medical Director, UWMF Ambulatory Clinic Operations
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine


_______________________________________________________________________________
Medical Director, UWMF

________________________________________________________________________________
Vice Chair, Department of Family Medicine