A Complete Guide to Respiratory Assessment for Nurses

Performing a respiratory assessment is key to many decisions in nursing. The respiratory assessment guides the decision to call in a doctor, begin emergency procedures to clear the airway, call a code, wait for more information, or proceed with more testing. Diligent practice of respiratory assessment is key here, since this enables nurses to proceed quickly through a respiratory assessment without sacrificing attention to detail. Seconds matter when there’s a respiratory emergency, so you or your team must be prepared to think quickly, critically, and clearly.

 

MET Testing

Before proceeding to any other step, you must assess for medical emergency team (MET) call criteria. If you need to call a code or enlist the assistance of other medical providers, you must be prepared to do so quickly. The four criteria for calling a medical emergency team are:

  • Abnormally slow or fast respiratory rate. In adults and older children, fewer than 8 breaths or more than 36 breaths per minute are an emergency. In newborns, the normal rate of respiration is between 30-60 breaths per minute, and anything outside of these parameters warrants an MET call.
  • A suspected or confirmed respiratory obstruction.
  • Pulse oximetry saturation reading below 90% despite oxygen treatment.
  • Any other signs of serious respiratory threat. If you are concerned that the patient’s life is in danger, you must make an MET call.

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The ABCs of Assessment

If the patient does not meet the criteria for an immediate MET call, if you are waiting on the MET team, or if you are part of an MET team making an assessment for what to do next, the simple acronym ABCDE can help you make life-saving decisions:

 

  • A—Airways: Is the airway patent? Check for blockages, and use a suction device to clear any obvious blockages.
  • B—Breathing: A pulse oximetry reading below 94% saturation demands oxygen treatment. Give oxygen until Sp02 exceeds 94%.
  • C—Circulation: Assess for signs of circulatory issues. Low blood pressure suggests the need for a fluid bolus. Chest pain that is clearly linked to a circulatory problem, or of indeterminate origin, demands an EKG.
  • D—Disability: If the patient is unconscious or shows signs of altered consciousness, assess for potential culprits. Look for dilated or pinpoint pupils that may indicate a drug overdose. Check the patient’s chart for drugs that may lead to hypotension. Loss of consciousness can have many causes, including hypoxia, hypotension, hypoglycemia, and neurological injuries.
  • E—Exposure: Save lives by saving time; expose the patient’s body for an exam. Remove clothing, while respecting the patient’s privacy and dignity. Move the patient to a private area if medically appropriate. Keep the patient warm with easily removed blankets.

 

Nurses treating neonates should call for assistance from a NICU or neonatal team, since interventions that can be life-saving in adults may be harmful in neonates.

 

The Importance of Quality Equipment

Hypoxia and other respiratory emergencies demand quality equipment. When seconds count, fumbling for a suction unit, looking for a cannula that fits, or dealing with equipment malfunctions can endanger your patients’ lives. Your agency needs quality equipment that’s ready to go, easily tested, and highly effective.

 

For help choosing the right portable suction device for your agency, download our comprehensive guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.

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