Skill 03[1]..Respiration.pdf

SKILL 3

Respiration

EQUIPMENT

Stethoscope

Watch with a second hand

6. Auscultate for normal, abnormal, and diminished and/or

absent breath sounds on both back and chest; use a reg-

ular pattern; compare breath sounds side-to-side.

7. Wash hands. Reduces transmission of microorganisms.

GENERAL GUIDELINES FOR VITAL SIGNS

1. Check record for baseline and factors (age, illness, med-

ications, etc.) influencing vital signs. Provides parame-

ters and helps in device and site selection.

2. Gather equipment, including paper and pen, for record-

ing vital signs. Promotes organization and efficiency.

3. Wash hands. Reduces transmission of microorganisms.

4. Prepare child and family in a quiet and nonthreatening

manner. Enhances cooperation and participation;

reduces anxiety and fear, which can affect readings.

DOCUMENTATION

Document the following in the appropriate place in the

client’s chart:

1. Rate, depth, and character of respirations.

2. Breath sounds heard and placement of sounds.

3. Any signs and symptoms of respiratory distress.

4. Who notified if findings of concern.

NOTE: Infants and young children may be quiet and

more cooperative if vitals signs are obtained while

child is sitting on caregiver’s lap.

PROCEDURE

1. Steps 1–4 of General Guidelines.

2. Be sure light is adequate for the procedure. Allows

accurate counting of respirations.

3. Place hand on chest or abdomen or observe rise and fall

of chest or abdomen. Count respirations for one full

minute for infants and younger children because respi-

rations are normally irregular. Count for one full minute

for any child with irregular respirations. For older chil-

dren with regular respirations, respirations may be

counted for 30 seconds and multiplied by 2 to obtain the

rate per minute. Respirations also may be counted by

auscultation. Counting for less than one minute may

lead to inaccurate respiratory rate in infants, young chil-

dren, and those with irregular respirations.

a. Respirations are diaphragmatic on children younger

than 7 years of age—observe or place hand on

abdomen.

b. Respirations are thoracic in children older than 7

years of age—observe or place hand on chest.

4. Observe movement of chest and abdomen.

a. Assess chest movements for symmetry.

b. In infants observe movement of abdomen.

Paradoxical abdominal movement, i.e., abdomen

rises on inspiration as chest retracts (see-saw move-

ment), is abnormal except in premature infants.

5. Observe for signs of respiratory distress (retractions,

nasal flaring, grunting, use of accessory muscles).

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