13.17 : 呼吸评估 I

Assessing the respiratory rate while counting the pulse is essential to prevent patient anxiety.

It provides accuracy of readings while maintaining the patient's comfort.

Observe the patient's chest movements and count their respirations for a full minute, or 30 seconds, to determine the total number of breaths. If counting for 30 seconds, multiply the breath count by two.

Make sure only to count one breath cycle at a time, which is one inhalation and one exhalation.

Document if the respiratory rate is abnormal. Usually, the normal respiratory rate is 12 to 20  breaths per minute.

Pay close attention to any changes in breathing patterns, for example, shortness of breath or pauses between breaths.

Document any changes in depth of breathing, nasal flaring, use of accessory muscles, and audible sounds, such as wheezing or crackles. 

Record any observations related to respiration rate, such as dyspnea or tachypnea.

Assess oxygen saturation through pulse oximetry or arterial blood gas values if necessary.

Document the findings in the flow sheet per institutional policy.