Oh sure, it sounds easy enough.  You just need to know how to count and how to look at someone’s chest rise, right?  WRONG.  Respirations are tricky mainly due to the fact you can’t let the patient know you are counting their breaths, otherwise their respirations will change (ie, they get nervous and breath faster). Many techs and nurses I’ve worked with make up their respirations.  You can tell this is the case because mysteriously all the patients on that floor have respirations of 18, and miraculously these respirations don’t change every 4 hours or between shifts.  It’s a miracle.  Not to mention, I’ve been told to “just chart 18” without having even seen the patient. I refuse to do this.  It’s irresponsible.

My charting consistently reflects respirations of 12, 14, 15; the nurses go crazy, as if the patient is about to code.  They tell me it’s not the patient’s normal.  I’d like to tell them the patient’s normal was made up in the first place so we should establish a new baseline.  Instead, I calmly nod and suggest the patient was most likely very relaxed when I saw them (and of course I chart whatever I counted regardless). But it took me a long time to even figure out the best way to count respirations.  I am determined to find a non-awkward way of accurately counting a patient’s breathing pattern without them knowing it.  It’s almost become a game for me.  I have tried all kinds of techniques:


The “arm to chest” move so you can count the radial pulse for 30 seconds (but really you’re counting/feeling the respirations). Or perhaps you really need to count the pulse so you do so for 30 seconds and count respirations for the other 30, telling the patient, “I’m going to count your pulse for 1 full minute.”  This move is awkward in bed with patients who are entirely annoyed that you are moving their arm to their chest for no good reason.  You can count a radial pulse with the arm straight; they figure this out quite quickly and wonder why you’re being retarded. Also, Dynamaps take the pulse automatically and patients know this so they are extra curious why you’re taking it manually.  However, it’s a solid back up technique if your Dynamap suddenly “isn’t working” this morning…


The “watching them while they sleep” tactic is a nice idea but real life never lets you use nice ideas. I walk up to a patient’s bed and stare at them while they sleep and the next thing I know they’re bolting up in bed asking me what the bad news is. Also, this technique requires me to wait for the patient to be sleeping, which we know isn’t a realistic expectation considering the time constraints we’re under.

The good 'ol fashioned way actually works 50% of the time.  You can tell the patient you're listening to their heart for 1 minute (another trick).  Two problems with this method.  First, it's really hard to hear things in fat people (which most patients are).  Second, the patient will ask

The good ‘ol fashioned way works 50% of the time. You can tell the patient you’re listening to their heart for 1 minute (another trick). Two problems with this method. First, it’s really hard to hear and sometimes feel things in fat people (which most patients are). Second, the patient will ask “So, how’s it sound?” so you either have to know what heart sounds you’re listening to or make up some kind of positive feedback that hopefully doesn’t contradict some doctor’s future diagnosis of heart failure.

The most effective technique I’ve found so far involves the Dynamap (automatic blood pressure machine).  If you’re not familiar with the machine yet, don’t worry; you will be soon enough!  It takes the BP, pulse, O2 saturation, and temperature of the patient.  Looks like this: 572225575_cab81d3680_o_dThis is the most efficient way I’ve found to do vitals thus far:

  • Turn the machine on.
  • Connect the pulse ox probe to the patient’s finger.  Wrap the BP cuff around the patient’s arm (make sure it’s the correct size/positioning) and attach the BP inflator cord to the cuff.
  • Take the temperature first.  While the temp is taking, the pulse ox and pulse should be calculating.
  • After those numbers have calculated, inflate the BP cuff.  Dynamap takes just about 30 seconds for a BP (sometimes 20 seconds).  As the BP is being taken, count the respirations.  Nine times out of 10 you’ll have enough time to count for 30 seconds, then double it.  Voila!  You have your vitals.

Some may argue counting respirations while taking BP will give you an inaccurate figure because the body reacts during BP readings (sometimes tensing up, person gets nervous, etc.).  By that logic, however, then the BP reading is inaccurate too.  There’s no perfect answer to a human problem but I know one thing: my technique is better than “just charting 18” any day of the week.