A registered nurse (RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP) may measure respiratory rate. When measurement is obtained by the UAP, any variance from previous measures is reported to the licensed caregiver.
Respirations are measured initially to obtain baseline data to assess the general status of each child within the first hour of admission to an acute care setting.
Respirations are measured before and immediately after respiratory interventions to assess response to treatment regimens.
Measurement of respirations is done every 4 to 8 hours in an acutely ill child and more frequently as clinically indicated.
EQUIPMENT
Stethoscope
Antiseptic wipes
Clock or watch with a second hand or digital readout
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Assess the child’s color, depth of respirations, presence of nasal flaring, grunting, retractions and type, use of accessory muscles and rhythm of respirations, the position that child assumes to breathe (e.g., sitting up or leaning forward), fussiness, and anxiety.
The presence of respiratory distress or apnea is a medical emergency and requires immediate intervention.
Explain to the child and family, using developmentally appropriate language, what you are assessing and why it is important. It is best to make a general statement about measuring how the heart and lungs are working rather than specifying that the respiratory rate is counted to avoid the child consciously controlling his or her respirations.
Measure the child’s respiratory rate first, before disturbing the child for other procedures that may affect the rate.
PROCEDURE Respiratory Rate
Steps
Rationale/Points of Emphasis
1 Review the child’s previous respiratory rate, when available.
Provides basis from which to make comparison.
2 Note the child’s medical diagnosis and history of respiratory problems or difficulties.
Alerts to potential respiratory problems.
3 Determine whether child is taking any medications that may affect respiratory rate or depth.
Medications can alter respiratory pattern (e.g., morphine can decrease rate and depth of respirations, salicylates can increase rate and depth).
4 Perform hand hygiene.
Reduces transmission of microorganisms.
5 Count respirations, preferably when the child is awake and calm or when asleep:
Ensures accurate measurement. Young children are primarily diaphragmatic breathers; older children depend more on their intercostal muscles.
5a Observe the abdomen for movement in infants and young children. Or place a stethoscope on the child’s chest and listen for respirations. Ensure the stethoscope chest piece is cleansed with an antiseptic wipe before and after examination.
Count respirations in infants for 1 minute. Infants are episodic breathers; it is normal for them to vary their respiratory rate and pattern. Counting for a full minute obtains a more accurate measure.
5b Observe thoracic movement in older children.
5c If respirations are regular, count number of respirations for 30 seconds and multiply by 2.
5d If respirations are irregular, count the number of respirations for 1 full minute.
6 Note depth and pattern of respirations, presence of anxiety, restlessness, irritability, and position of comfort. Observe child’s color, including extremities, noting cyanosis or pallor.
Alerts to respiratory distress and signs of hypoxia. Child may need immediate medical attention to prevent respiratory failure. Helps evaluate possible causes of respiratory distress.
If respiratory distress is noted, immediately auscultate breath sounds and immediately report this information to appropriate healthcare professional.
7 Perform hand hygiene.
Reduces transmission of microorganisms.
8 Record results; respiratory rate is recorded in breaths per minute.
Makes findings available to other health team members; indicates child’s status and allows comparison of measurements.
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The presence of respiratory distress or apnea is a medical emergency and requires immediate intervention.
PROCEDURE
Count respirations in infants for 1 minute. Infants are episodic breathers; it is normal for them to vary their respiratory rate and pattern. Counting for a full minute obtains a more accurate measure.
If respiratory distress is noted, immediately auscultate breath sounds and immediately report this information to appropriate healthcare professional.
