References:
- Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition, ISBN 9780135428733, by Audrey Berman, Shirlee J. Snyder, and Geralyn Frandsen (Ch. 28, pp. 532–569)
Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air into and out of the lungs. There are two types of breathing:
- Costal (thoracic) Breathing: external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. This is observed by the movement of the chest upward and outward.
- Diaphragmatic (abdominal) Breathing: involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement.
Respirations are controlled by (a) respiratory centers in the medulla oblongata and the pons of the brain, and (b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These respond to changes in O2, CO2, and H+ in the arterial blood to adjust respirations accordingly.
Assessing Respirations
Respirations are easily affected by activity and anxiety. Assessment should occur while the patient is resting. However, assessments may be done after exercise specifically to determine the client’s tolerance to activity. Before each assessment, the nurse must be aware of:
- The client’s normal breathing pattern.
- The influence of the client’s health problems on respirations.
- Any medications or therapies that might affect respirations.
- The relationship of the client’s respirations to cardiovascular function.
Respirations may be characterized by rate, depth, rhythm, quality, effectiveness, ease, and adventitious sounds.
- Rate: normally described in breaths per minute. Fast breathing is termed tachypnea, slow breathing is termed bradypnea, and normal breathing in rate and depth is eupnea. Apnea is a cessation of breathing for any period of time.
| Age | Pulse Average | Respiration Average |
|---|---|---|
| Newborn | 130 (80-180) | 35 (30-60) |
| 1 year | 120 (80-140) | 30 (20-40) |
| 5-8 years | 100 (75-120) | 20 (15-25) |
| 10 years | 70 (50-90) | 19 (15-25) |
| Teen | 75 (50-90) | 18 (15-20) |
| Adult | 80 (60-100) | 16 (12-20) |
| Older Adult | 70 (60-100) | 16 (15-20) |
Sleeping Respirations
A sleeping adult can have respirations lower than 10 breaths/min. Other vital signs must be used to validate the client’s condition.
- Volume: the amount of air (in liters) moving through the lungs. Hyperventilation results in an overexpansion of the lungs characterized by rapid and deep breaths, and hypoventilation results in an underexpansion of the lungs characterized by shallow respirations.
- Rhythm: many alterations of rhythm exist, but two common altered breathing patterns and sounds are Biot breathing (several short breaths followed by long, irregular periods of apnea) and Cheyne-Stokes breathing (waxing and waning, then temporary apnea).
- Ease or Effort: dyspnea is a general term for difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed. Orthopnea is dyspnea that occurs when in supine positions, and relieved by sitting upright, standing, or with the orthopneic position.
- Breath Sounds: sounds produced as air travels through the lungs and airways.
- Secretions: the expectoration of various substances from the respiratory tract such as blood (hemoptysis), sputum (productive cough), or the absence of any substance (nonproductive cough).
- Effectiveness: a measurement of whether or not the respirations are adequately oxygenating the blood and excreting carbon dioxide. This is quantified through oxygen saturation measurements via oximetry
Factors Affecting Respirations
- Rate: exercise, stress, and environmental factors (temperature, altitude [oxygen]), and some medicines can increase metabolism and sympathetic nervous system stimulation.
- Depth: normal inspiration and expiration takes in about 500 mL of air—the tidal volume. This may become deep or shallow with the same factors that affect rate, and positioning. Positions that allow better expansion of the chest will allow for a greater depth and tidal volume. A common complication related to this is supine leading to poor lung aeration, predisposing patients to the stasis of fluids and subsequent infection. Hyperventilation refers to very deep and rapid respirations; hypoventilation refers to very shallow respirations.
- Rhythm refers to the regularity of the expirations and inspirations. These are normally evenly spaced, but can become irregular.
- Quality or Character: aspects of breathing that are different from normal, effortless breathing. Two common aspects to consider is the amount of effort required (e.g., labored breathing) and breath sounds (e.g., wheezes).
- Sound of Breathing: normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear. Many sounds occur as a result of the presence of fluid in the lungs and are most clearly heard with a stethoscope. The following are breath sounds that are audible without amplification:
- Stridor: a shrill, harsh inspiratory sound due to laryngeal obstruction.
- Stertor: snoring or sonorous respiration, usually due to a partial obstruction of the upper airway.
- Wheeze: a continuous, high-pitched “musical” squeak or whistling expiratory sound.
- Bubbles: gurgling sounds heard as air passes through moist secretions in the respiratory tract.
Changes in Respirations Across the Lifespan
- Infants and Children: crying and anxiety will alter the respiratory rate.
- Infants and Young Children may breathe diaphragmatically. In rapid breathing, the nurse may place a hand on the abdomen to feel the rapid rise and fall during respirations.
- Most newborns are complete nose breathers, so nasal obstruction can be life-threatening. They can also experience “periodic breathing” where a pause for a few seconds occur between respirations which may be normal, but parents should be alert to prolonged or frequent pauses (apnea) that require medical attention.
- Older adults experience anatomic and physiologic changes that cause the respiratory system to be less efficient. Any changes in rate or type of breathing should be reported immediately.
| Breathing Pattern | Description |
|---|---|
| Costal/Thoracic Breathing | Breathing facilitated by the thoracic muscles/costals. Breathing in this way expands the thorax. |
| Diaphragmatic/Abdominal Breathing | Breathing facilitated by the diaphragm, the major respiratory muscle of the body. Breathing in this way expands the abdomen. |
| Eupnea | Normal breathing pattern |
| Tachypnea | Increased rate of breathing |
| Bradypnea | Decreased rate of breathing |
| Apnea | The cessation of breathing |
| Cheyne-Stokes Respirations | Rapid, shallow breathing interrupted by periods of apnea. |
| Kussmaul Respirations/Hyperventilation | Rapid, deep breathing often found in acidosis. |
| Biot Respirations | Irregular; non-rhythmic breathing patterns. This may be observed when the medulla oblongata has been damaged. |
| Apneustic | Prolonged inhalation and shortened exhalation breathing. |
| Agonal Breathing | Failure to breath due to brainstem injury |
Respiration Assessment Procedure
Assessing respirations is done to:
- Establish baseline data for subsequent evaluation.
- Identify whether the respirations are within the normal range
- Monitor respirations before or after the administration of a general anesthetic or medication that influences respirations.
- Monitor clients at risk for respiratory alterations (fever, pain, acute anxiety, etc.).
| Phase | Nursing Activities |
|---|---|
| Assessment | Assess skin and mucous membrane color (e.g., cyanosis, pallor), position assumed for breathing (e.g., use of orthopneic position), signs of lack of oxygen to the brain (e.g., irritability, restlessness, drowsiness, or loss of consciousness), chest movements (e.g., retractions between the ribs or above or below the sternum), activity tolerance, chest pain, dyspnea, medications affecting respiratory rate, and history of pulmonary conditions, smoking, exposure to toxic fumes, and living with others who smoke. |
| Planning | Assign: counting and observing respirations may be assigned to APs. The nurse bears the responsibility of follow-up assessments, interprets abnormal respirations, and determines appropriate interventions. Equipment: clock, timer, or watch with a sweep second hand or digital seconds indicator. |
| Implementation | For a routine assessment of respirations, determine the client’s activity schedule and choose a suitable time to monitor the respirations. Prior to performing the procedure, the nurse must introduce themselves and verify the client’s identity using agency protocol. Explanation of the nurse’s purpose, the procedure, and how the patient will participate.
|
| Evaluation | Compare the respiratory rate, rhythm, and depth to recent, baseline, or usual range for the age of the client and other vital signs or health status. Appropriate follow-up is conducted for notifying the primary care provider of any abnormalities or expression of dyspnea. Collaboration with other healthcare team members, such as the respiratory therapist, is arranged. |