Nurse Assistant in a LTC Facility Respiration Nurse Assistant in a LTC Facility

RESPIRATION Measures breathing of the patient Process of taking in oxygen et expelling carbon dioxide from the lungs et respiratory tract One respiration consists of one inspiration (breathing in, chest rises) et one expiration (breathing out, chest falls) Inhalation- act of taking in air Exhalation- act of breathing air out If you are unable to see pt breathing count how many times the abdomen rises et falls

Normal Respiratory Rate Respiratory rate- the number of respirations in 1 minute Resp. rate is affected by same factors as those that elevate or lower the pulse *Adult: 14-20 breaths per minute (There is no difference in Resp. range for an older adult) Wider Adult Range: 12 to 20 breaths per minute Teenagers: 12-16 Children: 16-25 breaths per minute Toddlers: 24-40 Preschool: 22-34 Infant: 30 to 50 breaths per minute

Characteristic of Respirations Normal Respirations Quiet Effortless Regular Both sides of chest rise et fall Note depth et quality of respirations deep shallow labored, difficult stertorus (abnormal sounds like snoring)

Rhythm Respiration Note rhythm with rate et character Regularity or equal spacing between breaths Described as regular (or even) or irregular

Abnormal RESPIRATION Eupnea: 16-20 breaths per minute normal pattern Dyspnea: difficult or labored breathing Apnea: absence of respirations Tachypnea: respiratory rate above 25 respirations per minute ex Response to fever Bradypnea: slow respiratory rate, usually below 10 respirations per minute; Ex response to drug overdose, sleep Orthopnea: severe dyspnea in which breathing is very difficult in any position other than sitting erect or standing

Abnormal RESPIRATION Cheyne-Stokes: periods of dyspnea followed by periods of apnea; frequently noted in a dying pt Rales: bubbling or noisy sounds caused by fluids or mucus in air passages

Abnormal Respiration Respiration brings fresh air into the body Example Caucasian pt breathing normally skin color pink Caucasian skin or nail bed is blue, gray or dusky= serious problem with intake et use of oxygen Dark skinned pt look at nail beds, lips et mucous membranes inside mouth!!

Voluntary Control of Respirations Partially under voluntary control Important to keep pts unaware of the procedure Because he or she may subconsciously or intentionally alter the pattern Do not tell the pt you are counting respirations Count pulse, Keep your hand on the pulse site when measuring respirations. Pts will think you are still taking pulse et the respirations will less likely be altered

Measuring Respirations You must be able to see the chest rise and fall The resident must not be aware that you are counting their respirations Count respirations right after counting pulse. The fingers should be left on pulse site. If resident has apnea, dyspnea, Cheyne-Stokes, or wheezing, report this to charge nurse immediately.

Record all Information Include: Rate Character Rhythm Example: Date, Time, R18 deep et regular, Your signature et title.