NUR 102
Fundamentals of Nursing
Assessing Respiration
Name _______________________________ Date _____________________
Instructor ____________________________ Results
Step
1. Determine client’s baseline respiratory and pertinent
laboratory values.
2. Explain procedure; assess for factors than influence
respiratory rate.
2. Assess respirations after pulse measurement. Keep
hands in place and slight pressure on radial pulse while
counting respirations.
3. Close door, pull curtain, raise side rails, raise bed to
working height. Perform hand hygiene.
4. Assist client to assume a supine position; place client’s
forearm across lower chest or upper abdomen with wrist
extended. Be sure client’s chest and abdomen are visible.
If necessary, move bed linens or gown.
5. Elevate head of bed 45 – 60 degrees.
6. Observe complete respiratory cycle (one inspiration and
one expiration).
7. Observe complete respiratory cycle (one inspiration and
one expiration)
8. Look at watch’s second hand, and count rate.
9. If respirations rhythm is regular, count rate for 30
seconds and multiply by 2.
10. If respirations rhythm is irregular or rate is less than 12,
or more than 20, count rate for 60 seconds.
11. Note depth and rhythm of ventilatory cycle.
12. Replace bed linens and client’s gown.
13. Raise side rails, lower bed
14. Wash hands
15. Document/report
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