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Breathing assessment

Eupnoea, normal rate and rhythm of breathing, describes unconscious, gentle respiration (Patton and Thiobodeau 2009). It is important to observe the patient and the way they are breathing, including:

the colour of the patient’s skin and mucous membranes, which can show how well perfused and oxygenated they are; look for any cyanosis

any use of accessory muscles or other respiratory signs

the rhythm, rate and depth of respiration

shape and expansion of the chest.

(Higginson and Jones 2009)

Skin colour

Cyanosis is a blue tone to the skin and mucous membranes (Parkman 2007). It can be either central, affecting the lips and oral mucosa, or peripheral, best observed by looking at the patient’s nail bed and skin (Simpson 2006). Peripheral cyanosis may be an indication of peripheral perfusion as it can be caused by vasoconstriction, whereas central cyanosis is more indicative of cardiorespiratory insufficiency. However, patients who are anaemic may not be cyanotic as there is insufficient haemoglobin (Moore 2007). Cyanosis is observable when oxygen saturations drop to 85–90% (Moore 2004b). A pale skin tone may indicate that the patient is anaemic or in shock (Bickley and Szilagyi 2009).

Use of accessory muscles

When the patient is in respiratory distress they may use their abdominal, sternomastoid and scalene muscles to increase respiration (Higginson and Jones 2009). To observe these, look at the patient’s neck during inspiration to see if there is any contraction of the sternomastoid or other accessory muscles (Bickley and Szilagyi 2009). In addition, some patients may breathe through pursed lips or have nasal flaring (Higginson and Jones 2009).

Rhythm, rate and depth of respiration

The normal respiratory rate is 12–18 breaths per minute with expiration lasting approximately twice as long as inspiration (Higginson and Jones 2009). The rate should be counted for 1 minute to fully assess both the rate and the rhythm (Moore 2004b). Patients with a respiratory rate greater than 24 breaths/min should have frequent observations and be closely monitored; if they also have other physiological alterations, they should receive prompt medical attention, as should all patients with a respiratory rate greater than 27 breaths/min (Cretikos et al. 2008). Respiratory rates which are 8 or less also require urgent medical care (Docherty 2002). Abnormalities in the rate and rhythm of breathing can take various forms, some of which are listed below.

Bradypneoa: breathing which is slower than the normal range; it may indicate respiratory depression or increased intracranial pressure or a diabetic coma (Bickley and Szilagyi 2009, Moore 2004b).

Tachypnoea: breathing which is faster than the normal range and shallow; can indicate a number of conditions including anxiety, pain, restrictive lung disease, cardiac or circulatory problems, or pyrexia (Bickley and Szilagyi 2009, Moore 2004b, Simpson 2006).

Dyspnoea: breathing where the individual is conscious of the effort to breathe and finds it more difficult; when dyspnoea occurs when the patient lies flat, it is termed orthopnoea (Patton and Thiobodeau 2009).

Apnoea: is a temporary cessation of breathing (Patton and Thiobodeau 2009).

Biot’s breathing: alternating periods of deep gasping with periods of apnoea, seen in patients with increased intracranial pressure and spinal meningitis (Patton and Thiobodeau 2009, Simpson 2006).

Cheyne–Stokes breathing: alternating periods of deep breathing with periods of apnoea; can have many causes including heart failure or brain damage (Bickley and Szilagyi 2009).

Hyperventilation: this is rapid but deep breathing and can be caused by anxiety, exercise or metabolic acidosis (Bickley and Szilagyi 2009).

Hypoventilation: is shallow and irregular breathing and can be caused by an overdose of certain anaesthetic agents or opiate drugs (Simpson 2006).

Shape and expansion of the chest

This part of the assessment involves looking at the anteroposterior