Respiratory Rate

Also Consider:  Hypoxia, Shortness of Breath 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Acute mental status change

• Not eating or drinking as much as usual

• Unrelieved pain

• If Pain:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Acute decline in ADL abilities

• Eyes: pupils dilated or constricted

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress, diminished respirations

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)

• Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis

• Alcohol intoxication or drug overdose (for potential opioid overdose, consider naloxone)

• Response to any ordered PRN medications (inhalers, nebs, nitroglycerin, oxygen) or repositioning

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Respiratory rate at rest persistently greater than 28 and above the patient’s baseline; OR 

  • Respiratory rate persistently lower than 10 and below the patient’s baseline (Consider administering Naloxone if unresponsive with diminished respirations)

• Notify medical staff on the next business day 

  • Change in the patient’s respiratory rate from baseline without other symptoms or signs of disease. 

4. Implement Management Plan

• Monitor vital signs every 4-8 hrs for 2-3 days

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Review status and plan of care with designated representative

• Update advance directives if appropriate

2025-04-27