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How to perform respiratory assessment

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Joyce Smith at University of Salford
Joyce Smith
Melanie Rushton at University of Salford
Melanie Rushton
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Art & science clinical skills
34 october 14 :: vol 30 no 7 :: 2015 NURSING STANDARD
How to perform respiratory assessment
Smith J, Rushton M (2015) How to perform respiratory assessment. Nursing Standard. 30, 7, 34-36.
Date of submission: October 13 2014; date of acceptance: December 4 2014.
Rationale and key points
This article aims to assist practitioners to perform a respirator y
assessment.
A logical and structured approach to respiratory assessment, such a s
the ‘look, listen and feel’ approach, should be undertaken.
The respiratory rate is an early indicator of deterioration of a
patient’s condition.
Signs of clinical deterioration should be responded to in a timely manner.
A track and trigger scoring tool can be used to evaluate physiological
data, develop a management plan and indicate future investigations.
Reflective activity
Clinical skills articles can help update your practice and ensure it
remains evidence based. Apply this article to your practice. Reflect on
and write a shor t account of:
1. How reading this article will change your practice when performing
a respiratory assessment.
2. Any further learning needs you have identified to extend your
professional development.
Subscribers can update their reflective accounts at: rcni.com/portfolio.
Authors
Joyce Smith Lecturer in adult nursing.
Melanie Rushton Lecturer in adult nursing.
Both at University of Salford, Salford, England.
Correspondence to: J.Smith2@salford.ac.uk
Keywords
assessment, clinical procedures, clinical skills, respiratory care
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Preparation and equipment
The environment should be safe to minimise risk
to the practitioner and the patient. The patient’s
bed area should be assessed for any furniture or
wires that may cause a risk.
The patient’s privacy and dignity should be
maintained by drawing the curtains around
the bed.
The patient should be rested and in a comfortable
position for the assessment. If not, the practitioner
should ask for help to position the patient
before starting the assessment. This may not be
appropriate if the patient is acutely unwell.
The practitioner should ensure that all
equipment required is available and in good
working order, including:
– A watch (or clock) with a second hand.
– A stethoscope.
– A pulse oximeter.
– An early warning score chart.
Hand hygiene should be performed (Hillier 2015).
Procedure
1. Assess the patient’s respirations after checking
the pulse, so that the patient does not alter
their breathing.
2. Count the respiratory rate for one minute.
The normal resting respiratory rate is
between 12 and 20 regular and rhythmic
breaths per minute.
3. Undertake the ‘look, listen and feel’
approach to assessment, as advocated by the
Resuscitation Council (UK) (2011).
Look
4. Observe the rhythm, symmetry and depth of
the patient’s respirations. Extra respiratory
effort is indicated by the patient pursing
their lips or flaring their nostrils. Evidence
of the patient using their accessory muscles,
for example abdominal or scalene muscles,
indicates increased work or difficulty
breathing. Any sign of tracheal deviation may
indicate a tension pneumothorax.
5. Observe the patient’s colour – pale or flushed
– and whether they are showing any signs
of cyanosis. Peripheral cyanosis is a bluish
colour of the skin and nail beds that indicates
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