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Clinical Nursing Skills

15.6 Respiration

Clinical Nursing Skills15.6 Respiration

Learning Objectives

By the end of this section, you will be able to:

  • Distinguish variations in respirations by age groups
  • Describe characteristics of respirations
  • Identify factors affecting respiration rates

Obtaining respirations, or breathing pattern, is another aspect of checking vital signs. One respiration is complete inspiration and exhalation. Inspiration is the intake of air into the lungs where gas exchange occurs. During inspiration, the diaphragm relaxes, enlarging the lung fields and lowering the pressure within the thoracic cavity to allow for an increase in lung volume. Exhalation is the removal of air from the lungs following gas exchange. During exhalation, the diaphragm contracts, reducing the lung fields and increasing the pressure within the thoracic cavity. The process of gas exchange is the absorption of oxygen from the inhaled air into the blood and the removal of carbon dioxide from the blood. The oxygen and carbon dioxide saturation in the blood signals to the brain to increase, decrease, or maintain the respiratory rate. Obtaining the respiratory rate verifies that the patient is breathing and not in respiratory distress while also ensuring the rhythmic exchange of oxygen and carbon dioxide. For routine vital sign assessment, the nurse obtains the respiratory rate by observing the rise and fall of the chest immediately following the pulse check.

Variation of Respirations by Age

For adults, the respiratory rate is 12 to 20 breaths per minute, but for infants and children, their normal rate is increased. A newborn, for example, has an expected respiratory rate of 30 to 60 breaths per minute. Table 15.8 summarizes the normal ranges of respiratory rates across the life span.

Age Respiratory Rate
Infant 30 to 60 breaths per minute
Toddler 20 to 30 breaths per minute
Preschooler 20 to 25 breaths per minute
School age 14 to 22 breaths per minute
Adolescent 12 to 18 breaths per minute
Adult 12 to 20 breaths per minute
Table 15.8 Respiratory Rates across the Life Span

Life-Stage Context

The Rationale for Higher Heart and Respiratory Rate in the Pediatric Population

Infants’ and children’s respiratory and heart rates are normally faster than those of adolescents and adults. The fastest ranges are in neonates. As humans age, respiratory rates gradually shift with age to an adult range sometime in late childhood or early adolescence. One reason for this normal increase is that infants and children have a faster metabolism, which is needed for their rapid growth and development. Another reason for this increase is the smaller size of the heart and lungs. To maintain adequate perfusion and oxygenation, the heart and lungs will have to work faster since they are handling a smaller volume than adults (Cleveland Clinic, 2023).

Oxygen Saturation

The efficiency of the respiratory system is assessed not only through obtaining the respiratory rate but also by assessing the oxygen saturation of the blood, abbreviated as SpO2. The respiratory system’s function is to promote gas exchange and oxygenate the blood. To assess if blood, specifically hemoglobin, is being adequately oxygenated, a pulse oximeter is used during obtainment of vital signs. The normal range for oxygen saturation (SpO2) at all ages is 96 to 100 percent, meaning that the hemoglobin is thoroughly saturated. At times, a patient’s expected oxygen saturation trends may vary from this range. Examples include those with structural heart abnormalities and those with COPD. COPD causes a normal oxygen saturation that ranges from 88 to 93 percent.

Pulse Oximeter Readings

The pulse oximeter assesses the oxygen saturation of hemoglobin by placing a probe most commonly over a finger. The pulse oximeter may be ordered as continuous monitoring with parameters set or scheduled to be obtained with vital signs (Figure 15.24). In infants and young toddlers, the continuous probe may be inserted on the big toe to avoid patient interference with the monitor. In neonates, the probe may be placed around the baby’s foot. This type of probe may be attached to an infant’s foot or toe as well.

Pulse oximeter attached to patient's finger with tape
Figure 15.24 In continuous monitoring, the probe is attached to the patient’s finger with tape. (credit: “Pulse oximeter with sensor taped around finger” by Ryerson University, CC BY 4.0)

Real RN Stories

Standard Supply Room Equipment: Nail Polish Remover

Name: Jessica, RN
Clinical setting: Emergency department
Years in practice: 14
Facility location: Wilmington, North Carolina

As a new nurse, I remember trying to find supplies in the supply room. Whenever I would go in there to hunt for something, it would seem to take forever to find it. One time I needed to restock alcohol prep pads and grabbed a handful of individually packaged pads. It was only when I went to the room that I realized I grabbed nail polish remover instead of alcohol prep pads. Imagine my embarrassment pulling out nail polish remover to try to clean my patient’s IV site. After that incident, I asked an experienced nurse why we kept nail polish remover in the unit supply room. It just did not make sense. The nurse told me that nail polish can hinder the pulse oximeter’s reading because it prevents the light from analyzing the red blood cells. From my silly mistake, I learned that nail polish remover is actually an important supply kept on the units, and I always keep a few with me just in case the pulse oximeter cannot pick up the patient’s oxygen saturation through painted fingernails.

Some pulse oximeters show the wavelength of the pulse along with the pulse rate and oxygen saturation (Figure 15.25). This wavelength can provide more information regarding the accuracy of the reading. A rhythmic wavelength that mimics the palpated pulse should be displayed on the screen. Artifact, an abnormal, chaotic wavelength, is most likely due to movement or improper placement of the probe.

Pulse oximeter attached to patient's finger
Figure 15.25 Some pulse oximeters display the regular wavelength, in addition to the oxygen saturation (SpO2) and pulse rate. (credit: U.S. Agency for International Development/Flickr, CC0)

Clinical Safety and Procedures (QSEN)

QSEN Competency: Pulse Oximetry

See the competency checklist for Pulse Oximetry. You can find the checklists on the Student resources tab of your book page on

Respiration Characteristics

When obtaining the respiratory rate, the nurse should observe the rise and fall of the patient’s chest. When observation alone is insufficient, the nurse may need to use the stethoscope to auscultate the respiratory rate. The stethoscope should remain in one place over the patient’s lung field. When assessing the respirations, the nurse needs to take note of the breaths per minute, also known as the respiratory rate, rhythm, and depth of respiration. Unlabored breathing should be audibly quiet.


A nurse first checks the respirations for the breaths per minute. This is done after the nurse obtains the heart rate. Once the heart rate is obtained, the nurse does not remove their fingertips from the pulse site but simply shifts their gaze to the rise and fall of the chest. There is no need to let the patient know their respiratory rate is being obtained because the knowledge could cause the patient to unknowingly alter their breathing pattern. The normal adult respiratory rate is 12 to 20 breaths per minute. When the respiratory rate exceeds 20 breaths per minute, tachypnea occurs. It can occur due to physical changes or emotional ones, such as anxiety and fear. When the rate is below 12 breaths per minute, bradypnea occurs. A lower-than-normal respiratory rate is also called respiratory depression, a side effect of anesthetics and opioids.


While the nurse is counting the rate, it is important to also note the regularity of the respirations. A healthy pattern is a regular pattern of respiration, whereas an irregular pattern may warrant the need for further investigation. Irregular breathing could also occur when the patient is aware that the nurse is counting their respirations. Respirations are both an involuntary and voluntary action, meaning that an individual may purposefully breathe faster or slower, or sigh, but will also continue to breathe without consciously thinking about it. The heart beating, on the other hand, is strictly an involuntary action controlled by the brainstem.

A nurse may encounter several irregular respiratory rhythms among patients. Shallow breathing occurs with hyperventilation, pain, and pneumonia. Tachypnea occurs in times of hypoxia and respiratory distress or emotional distress. A more rapid and deep pattern or rhythm of breathing experienced primarily with diabetic ketoacidosis is called Kussmaul respiration. Another abnormal rhythm is Cheyne-Stokes respiration. It is characterized by periods of rapid and shallow breathing followed by a period of apnea, a complete cessation in breathing. Agonal breathing occurs at the end of life and mimics Cheyne-Stokes respiration. Cheyne-Stokes respiration is a mixture of complete apnea and respiratory failure.


While observing the rate and rhythm of the respirations, the nurse should also note the depth of the breaths. That is, note if the breathing is shallow or deep. A healthy breathing depth is neither shallow nor deep but enough to cause the chest to rise and fall. Breathing that is too shallow is often seen postoperatively with chest or abdominal surgeries because pain hinders an adequate breath. If this continues, atelectasis, collapsing of the alveoli, can develop and progress to larger portions of the lungs. In contrast, deep breathing, a sign of respiratory distress, is seen when the body is attempting to increase the oxygenation of the blood or blow off excess carbon dioxide.

Factors Affecting Respiration Rates

The respiration rate is affected by acid-base imbalances, pulmonary complications, neurological issues, and increased metabolism. Since carbon dioxide is an acid, an acid-base imbalance will affect a patient’s breathing pattern. The two main categories of an acid-base imbalance are acidosis, the excess of acid or loss of base, and alkalosis, the loss of acid or excess of base. When the body enters acidosis because of nonpulmonary issues, the pulmonary system attempts to compensate by expelling its acid, carbon dioxide. This is accomplished through tachypnea and hyperventilation. Conversely, when alkalosis is present due to nonpulmonary issues, the lungs compensate by holding onto its acid through hypoventilation and bradypnea.

Pulmonary complications are a major cause of respiratory abnormalities. When a patient is in respiratory distress, tachypnea and dyspnea, difficulty breathing, are the first signs exhibited. Another sign of respiratory distress is accessory muscle use, which includes using voluntary muscles to aid in the process of breathing. Pulling of the neck muscles and nasal flaring are just two examples of this. Left-sided heart failure also affects the pulmonary system by causing a backup of blood into the lungs. Because of the buildup of blood, the patient will have a difficult time breathing and may be unable to lay down, known as orthopnea.

Concerns in the central nervous system affect respirations since the medulla is the respiratory control center. Any damage that affects the medulla will affect respiration. Severing of the spinal cord at or above C4 will cause paralysis of the diaphragm and the inability to breathe. After a seizure, chaotic firing in the brain, the person will enter a postictal state (altered level of consciousness after seizure activity), which may cause bradypnea. Opioids and anesthetics are known to depress the respiratory system as well. This is why it is vital that a nurse obtains the respiratory rate prior to administration and monitor it closely while a patient is receiving medications known to cause respiratory depression.

Conditions that increase metabolism also increase the respiratory rate. These include fever and hyperthyroidism. Infants and children also tend to have a faster metabolic rate than adults, which causes a faster normal respiratory rate in these young patients.

Unfolding Case Study

Unfolding Case Study #3: Part 3

Refer to Unfolding Case Study #3: Part 2 to review the patient data.

Flow Chart 1230:
Blood pressure: 142/78
Heart rate: 112 beats per minute
Respiratory rate: 29 breaths per minute
Temperature: 99.6°F (37.5°C)
Oxygen saturation: 82 percent on room air
Pain: 3/10
Take action: Based on the patient’s vital signs, what interventions should the nurse implement immediately?
Evaluate outcomes: The nurse contacts the provider about the patient’s vital signs and is told to put the patient on 2 L oxygen via nasal cannula. What assessment findings would indicate that this intervention was successful?

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