Copyright EMAP Publishing 2018 This article is not for distribution

Clinical Practice Keywords Respiratory rate/NEWS 2/ Deteriorating patient/ Review This article has been Respiratory double-blind peer reviewed In this article... ● Why respiratory rate is a vital sign ● The reasons why nurses fail to measure respiratory rate accurately ● Negative patient outcomes from failure to identify and record changes in respiratory rate

Respiratory rate 1: why measurement and recording are crucial

Key points Author Carol Kelly is head of department, applied health and social care, Poor recording and Faculty of Health and Social Care, Edge Hill University and chair of the Respiratory lack of escalation Nurse Research Consortium, a sub-committee of the Association of Respiratory of abnormal vital Nurse Specialists. signs results in poor outcomes Abstract Respiratory rate is a vital sign but it is frequently omitted, inaccurately for patients measured and not recorded. This article, the first in a six-part series on respiratory rate, explores the importance of respiratory in acute care. The article also Vital signs explains why nurses need education, skills and knowledge to assess this neglected monitoring needs vital sign. to be prioritised in workload planning Citation Kelly C (2018) Respiratory rate 1: why accurate measurement and recording are crucial. Nursing Times; 114: 4, 23-24. A change in respiratory rate is one of the first signs espiratory rate (RR), or the Early detection of deterioration of deterioration number of breaths per minute, The National Institute for Health and Care is a clinical sign that represents Excellence (NICE) (2007) recommends that Nurses cite poor ventilation (the movement of patients in acute hospitals should have: R ●  knowledge, lack of air in and out of the ). A change in RR Vital signs recorded on admission to time and reliance is often the first sign of deterioration as the hospital (Box 1); on clinical body attempts to maintain oxygen delivery ● A written care plan outlining which judgement as to the tissues. observations should be recorded and reasons for failing Failing to recognise the early signs of their frequency. to record deterioration can result in poor outcomes Nevertheless, poor monitoring con- respiratory rate for patients. In a review of abnormal vital tinues to raise concerns (Resuscitation signs, Cretikos et al (2008) found that more Council (UK), 2015). Respiratory rate than half of patients who had a serious In a move to improve the early identifi- should be interpreted adverse event could have been identified as cation of deteriorating patients, NICE alongside presenting high-risk up to 24 hours previously. Jon- (2007) suggested that acute hospitals clinical features and sson et al (2011) suggested that early detec- should adopt physiological track-and- other aspects of tion and documentation of changes in vital trigger systems or early warning scores signs, particularly RR, could help to detect (EWS) for all adult patients. respiratory failure, which is the most In 2012, the Royal College of Physicians common primary cause of admission to (RCP) published the first National Early intensive care. Warning Score (NEWS) with the aim of Studies show that increased RR can be standardising practice; an updated version used to help predict patients at risk of car- (NEWS 2) was launched in 2017. NEWS 2 is diac arrest. For example, a retrospective based on a simple scoring system of six study showed that a RR of >27 breaths/min physiological parameters; a score is allo- is a better predictor of a cated to each parameter and an overall within 72 hours than or blood score is then aggregated. These parameters

ALAMY pressure (Fieselmann et al, 1993). are aligned with the RCUK (2015) ABCDE

Nursing Times [online] April 2018 / Vol 114 Issue 4 23 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution Clinical Practice This article is funded by Review an educational grant from PMD Solutions assessment tool for critically ill patients. deterioration patients’ SpO may appear to Box 1. The vital signs 2 NEWS 2 has been validated in many set- be in the normal range, but the RR will tings and is endorsed by NHS England and Vital signs are: increase in response to inadequate oxygen- NHS Improvement for use in England. l Heart rate ation (Mok et al, 2015); this will be dis- l Respiratory rate cussed in more detail in part 3. Failing to monitor vital signs l Systolic Measuring RR is acknowledged to be a core l Level of consciousness Conclusion nursing skill, yet evidence suggests that it l Oxygen saturation The monitoring and recording of RR is is an under-reported sign and is often esti- l Temperature part of a full patient assessment. It should mated by nurses (Flenady et al, 2016). A be interpreted in the context of other pre- post-operative study of 211 patients found Purpose of vital signs monitoring: senting clinical features, together with that over 15% of RR records were undocu- l Fundamental part of patient other aspects of respiration, for example mented (McGain, 2008). Inaccurate assessment the depth, pattern and effort of recording or assuming that patients’ RR is l Provide a baseline and determine (see part 4). NT within normal range is another issue. the patient’s usual range Semler et al (2013) found a significant dif- l Assist in identifying deterioration References ference between actual RR and the one or improvement in a patient’s Cretikos MA et al (2008) Respiratory rate: the that was recorded; out of 368 recordings, condition neglected vital sign. Medical Journal of Australia; nearly 72% showed 18 or 20 breaths/min l Help to determine the level of care 188: 11, 657-659. Dougherty L, Lister S (2015) The Royal Marsden required despite the fact that only 13% were actually Manual of Clinical Nursing Procedures. Oxford: within that range. Wiley-Blackwell. In practice it can be difficult to measure Vital signs should be: Elliott M (2016) Why is respiratory rate the RR accurately as patients may alter their l Measured at least once every 12 neglected vital sign? A narrative review. breathing if they know they are being hours unless specified otherwise International Archives of Nursing and Health Care; 2: 3, 1-4. watched; this can be addressed by tech- l Recorded on admission Fieselmann JF et al (1993) Respiratory rate l  niques such as discreetly counting respira- Documented clearly predicts cardiopulmonary arrest for internal tions while appearing to check the radial l Considered as part of a holistic medicine inpatients. Journal of General Internal (see part 3). assessment Medicine; 993; 8: 7, 354-360. Evidence suggests that nurses’ failure l Form part of an early-warning Flenady T et al (2016) Accurate respiratory rates to record RR is due to poor knowledge, scoring system count: So should you! Australasian Emergency Nursing Journal; 20: 45-47. subjective assessments about whether to Sources: Dougherty and Lister, 2015; Jonsson T et al (2011) Nursing documentation assess respirations and a lack of time NICE, 2007 prior to emergency admissions to the intensive (Elliott, 2016). Mok et al (2015) suggested care unit. Nursing in Critical Care; 16: 4, 164-169. that vital signs monitoring needs to be pri- McGain F et al (2008) Documentation of clinical oritised in workload planning, while The use of NEWS 2 (RCP, 2017) has review and vital signs after major surgery. Medical Elliott et al (2016) highlighted a lack of helped to standardise the approach used Journal of Australia; 189: 7, 380-383. Mok W et al (2015) Attitudes towards vital signs guidance on who should measure vital by healthcare organisations, however it is monitoring in the detection of clinical signs and suggested that vital signs moni- still important that the patient’s individual deterioration: scale development and survey of toring may be seen as “just another task”. normal parameters are taken into account ward nurses. International Journal of Quality in From the evidence it appears that staff and this may require modification to the Health Care; 27: 3, 207-213. do not prioritise measurement of RR, and EWS. For example, a patient with chronic National Institute for Health and Care Excellence (2007) Acute Illness in Adults in Hospital: lack of automation is cited as a possible obstructive pulmonary disease may have a Recognising and Responding to Deterioration. reason. While vital signs such as pulse and higher baseline RR or lower oxygen satura- Nice.org.uk/CG50 can be measured using tion than the normal range – in this case a Resuscitation Council (UK) (2015) The ABCDE automated machines, technology is not modified score may be agreed by the Approach Bit.ly/ABCDEResus widely available for respiratory moni- multidisciplinary team. Royal College of Physicians (2017) National Early toring (Elliott, 2016). Nurses need to be aware that a small Warning Score (NEWS) 2. Bit.ly/NEWS2RCP Semler M et al (2013) Flash mob research: a change in a patient’s normal RR of single-day, multicenter, resident-directed study of Problems defining normal RR 3-5 breaths/min could be an early sign of respiratory rate. Chest; 143: 6, 1740-4. While there is an accepted definition for a deterioration (Dougherty and Lister, 2015). normal pulse (60-100 beats/min) a variety Respiratory monitoring should always be Respiratory rate series of ‘normal ranges’ for RR is cited in the lit- part of a holistic patient assessment, and Part 1: Why accurate measurement and erature. The normal accepted range for an patients whose RR is outside of the normal recording are crucial adult is 12-20 breaths/min (RCP, 2017; range should be closely monitored with Part 2: Anatomy and physiology of breathing RCUK, 2015), however this can vary frequent observation and recording of Part 3: Procedure for measuring according to the patients’ age and medical vital signs. respiratory rate condition. It is generally accepted that a There is a concern that nurses rely on Part 4: Respiratory rhythms and chest rate of >25 breath/min or increasing RR can pulse oximetry as a replacement for RR to movement indicate that a patient may deteriorate evaluate respiratory dysfunction (Mok et Part 5: Respiratory rate and the deteriorating suddenly (RCUK, 2015). Likewise, a rate al, 2015). However, pulse oximetry meas- patient of<8 breaths/min, or a decreasing RR can ures oxygen saturation while RR measures Part 6: Using technology in respiratory assessment also signify deterioration. ventilation. During early stages of

Nursing Times [online] April 2018 / Vol 114 Issue 4 24 www.nursingtimes.net