How to count respirations: teaching CNA vital signs

To count respirations, watch the resident's chest or belly rise and fall for one full minute with a watch that shows seconds, and count each rise and fall as one breath. Do it without announcing it. Keep your fingers resting on the resident's wrist as if you were still taking the pulse, and record the total as breaths per minute.

That's the method as the open Nursing Assistant textbook from Chippewa Valley Technical College teaches it: "Respirations are documented as the number of breaths per minute, with each cycle of inspiration and exhalation counting as one breath." Its skills checklist for respirations has one line for the count itself: "Count respirations for 60 seconds."

This post covers the radial pulse and respirations from the teaching side: why the count is done quietly, what counts as a breath, which errors turn up in the lab, and how an instructor confirms that the number a student wrote down is real.

A resident who knows someone is watching their breathing will often breathe differently. The textbook puts it plainly: "the most accurate measurement is obtained when the client is not aware you are watching their breathing; knowing they are being observed can unconsciously change their breathing pattern."

Its answer is the habit your students should leave the lab with: "many nursing assistants count the client's respirations while they appear to be taking their pulse." The book calls this "one exception to the standard rule of explaining to the client what you will be doing." So the order is pulse first, respirations second, with the fingers never leaving the wrist.

One wrinkle to flag for students. The respirations step in the NNAAP skills list published by Credentia reads "Explains procedure (for testing purposes), speaking clearly, slowly, and directly." In the evaluation they explain; on the unit, the book's habit applies. Which of the two your program drills first is your call, but say out loud that there are two, because a student who has memorized only one will either fail a step or change the number. Credentia's skills list is a public PDF.

Three practical points from the same section help students count well:

• Where to look: the shoulders moving up and down, the chest or stomach rising and falling, or the clothing around the ribs moving.
• Why it's hard: it can be difficult to see a complete respiratory cycle, so students need quiet time to learn to follow one.
• Keep the room quiet: the resident may need to be asked to stay quiet, "because talking or moving changes the respiratory rate."

The radial pulse is the one nursing assistants take most, "because it is easily accessible." The textbook's instructions for finding it: ask the resident to hold the palm of their hand upward, draw an imaginary line from the extended index finger past the wrist to the radial bone, and palpate "just inside the radial bone." The Credentia skills list says the same thing in checklist form: "Places fingertips on thumb side of client's wrist to locate radial pulse."

Use the index and third fingers. The textbook is firm about the thumb: "never use the thumb because it has its own pulse, and you may inadvertently count your own heart rate rather than the heart rate of the client." It's the first thing to check when a student's number is far from yours.

The resident should be seated comfortably with arms and legs uncrossed. If they're lying down, that can lower the heart rate, so the position is documented. The book calls a full 60 seconds "best practice," especially when the rhythm is irregular, and an irregular pulse is documented and reported to the nurse.

Here are the two skills side by side. The exam columns come from the NNAAP Skills List published by Credentia (the 2018 national list and a 2023 version, whose Skill 6 and Skill 7 wording matches), and the rest from the textbook.

The recorded number carries the weight. On both skills, the only bold line, which the skills list marks as a Critical Element Step, is the one that records the rate within the evaluator's tolerance. Hand washing before recording, the signaling device within reach and the explanation each have their own lines, but the recorded number is the line the list singles out.

The sources agree on the count time: a full minute. The tolerance appears in the Credentia list and not in the textbook, which teaches the technique without grading it. If a program uses a different provider or its own checklist, the checklist your program follows decides.

These are the errors worth watching for in the skills lab, each tied to a line in the sources:

• Thumb on the wrist. The student feels a strong, steady beat and counts their own pulse. The tell is a number that's close to their own resting rate.
• A short count. Fifteen or thirty seconds, then multiplied. Both sources call for the full minute, and the textbook adds that an irregular rhythm is the reason.
• Announcing the respiration count. "I'm going to watch you breathe now" is the quickest way to change the number.
• Counting over a conversation. Talking and moving change the respiratory rate, and the student also loses the cycle.
• Skipping the end of the task. The checklists finish with hand hygiene and the call light within reach, and the textbook adds documenting the rate and reporting abnormal findings to the nurse. The number isn't useful until it's charted (see CNA charting: how to teach it before the first shift). Residents who are restless or talkative make both counts harder, since talking and moving change the rate; the post on dementia care in nursing homes covers how students can approach them.

Hand hygiene before recording is the easiest line to drop once a student is concentrating on a count; see infection control training for CNAs for the steps that slip most.

A student can write down a believable number without having counted anything, so the instructor needs a second count to compare against. One way to run it, borrowing the exam's two tolerances:

• The student takes the pulse on one wrist while you take it on the other, both for a full minute, with no talking and nobody saying a number until the minute is up.
• For respirations, you count silently from where you stand while the student counts as in the lab, fingers on the wrist.
• Both numbers go on paper before anyone compares. Within 4 beats or 2 breaths matches the exam's tolerance; outside it, the student redoes the count while you watch their hands and eyes.

If your lab already rotates students through stations, as in teaching CNA classes built around the skills lab, this fits one station well: a pair counts, a third student watches the clock and the checklist.

To finish with an exercise: give each pair three rounds, pulse then respirations, and record both students' numbers and the difference for every round. A student who is outside tolerance twice in a row is usually making one of the errors above, and the lab sheet shows which count was off, so you know which one to look for in the next round.