ICU Respiratory Assessment – Nursing Documentation 

Rate and Depth of Respiration 

Assessment: Observe respiratory rate, rhythm, and depth for a full 60 seconds. 
Documentation Example: 
RR 18 breaths/min, regular rhythm, moderate depth. 

Pulse Rate 
Assessment: Measure via cardiac monitor or palpation and correlate with respiratory status. 
Documentation example: 
HR 92 bpm, sinus rhythm. 

Skin Colour 
Assessment: Inspect lips, nail beds, mucous membranes, and overall skin tone. 
Documentation example: 
Skin pink, warm, dry; no cyanosis noted. 

Pulse Oximetry (SpO₂) 
Assessment: Ensure accurate probe placement and note oxygen delivery method. 
Documentation Example: 
SpO₂ 96% on FiO₂ 0.40 via venture mask. 

Use of Accessory Muscles 
Assessment: Observe neck, intercostal spaces, and abdominal muscles. 
Documentation Example: 
No accessory muscle use observed. 

End-Tidal CO₂ (ETCO₂) 
Assessment: Monitor numeric value and waveform via capnography. 
Documentation Example: 
ETCO₂ 4.5KPa with normal waveform. 

Sputum 
Assessment: Assess amount, colour, consistency, and odour. 
Documentation Example: 
Moderate amount of thick yellow sputum (suctioned via ETT/orally). 

Documenting ICU Respiratory Note – example 

Respirations 18/min, regular and unlaboured. SpO₂ 96% on FiO₂ 0.40 via ventilator. ETCO₂ 4.5KPa with normal waveform. Chest expansion symmetrical; no accessory muscle use noted. Skin pink, warm, no cyanosis. HR 92 bpm sinus rhythm. Moderate thick yellow sputum obtained on suctioning. 

Appropriate Nursing Responses to Respiratory Observations 

Repositioning the Patient 
Intervention: Reposition patient to optimise ventilation (to improve V/Q ratio) and secretion clearance (e.g., upright, lateral, or prone as indicated). 
Documentation Example: 
Patient repositioned to high Fowler’s position (sititng upright in bed on back). Improved chest expansion noted; SpO₂ increased from 92% to 96%. 
Note: Ventilation/Perfusion (V/Q) matching is key in optimizing ventilation.  In principle, fluid (and blood) moves down and air being less dense moves up).  Therefore to optimize ventilation in a patient who has poor respiratory function prone position (laying on their front) may be necessary to allow the bases of the lungs (situated posterially) to freely receive air whilst perfusion is optimized in the apices and midzones. 

Working with the Physiotherapist 
Intervention: Collaborate with physiotherapy for respiratory treatments such as chest physiotherapy, mobilisation, or airway clearance techniques. 
Documentation Example: 
Reviewed with physiotherapist. Chest physiotherapy completed; patient tolerated intervention well with increased sputum clearance. 

Encouraging Deep Breathing and Coughing 
Intervention: Encourage deep breathing, coughing exercises, or use of incentive spirometry as appropriate. 
Documentation Example: 
Patient encouraged to perform deep breathing and coughing exercises. Effective cough produced; small amount of sputum expectorated. 

Integrated ICU Nursing Progress Note Example 
Respiratory observations reviewed. Patient repositioned to upright position with improved oxygenation noted. Physiotherapist consulted and chest physiotherapy performed. Patient encouraged with deep breathing and coughing exercises; effective cough achieved. Ongoing monitoring continued.