fundamental nursing skills.

fundamental nursing skills .Contents Acknowledgements Preface Contributors Introduction xi xiii xv xvii Chapter 1 Breathing Penelope Ann Hilton 1 Introduction Common terminology Assessing an individual’s ability to breathe Monitoring respiratory rate Monitoring peak flow Maintenance of an airway Monitoring expectorant Disposal of sputum/oral secretions Obtaining a sputum specimen Administration of oxygen Artificial respiration (rescue breathing) References and further reading Chapter 2 Mobilizing Samantha Athorn and Penelope Ann Hilton 20 Introduction Common terminology Assessing an individual’s ability to mobilize Moving and handling Care of an individual who is falling Care of an individual who has fallen References and further reading v vi Fundamental Nursing Skills Chapter 3 Personal cleansing and dressing Alyson Hoyles, Penelope Ann Hilton and Neal Seymour 43 Introduction Common terminology The skin Assessing an individual’s ability to cleanse and dress Making a bed or cot Changing linen on an occupied bed or cot Disposal of linen Assisting individuals with bathing Assisting individuals with oral hygiene Assisting individuals with eye care Facial shaving Hair care Assisting individuals to dress References and further reading Chapter 4 Maintaining a safe environment Julie Foster and Penelope Ann Hilton 75 Introduction Common terminology Personal safety Principles of health and safety at work Universal precautions Principles of asepsis Monitoring a client’s pulse Monitoring blood pressure Responding in the event of a cardiopulmonary arrest Administration of medicines Responding in the event of a fire Assessing an individual’s ability to maintain a safe environment References and further reading Chapter 5 Eating and drinking Catherine Waskett 128 Introduction Common terminology Assessing an individual’s nutritional status vii Contents Assessing an individual’s hydration status Assisting clients in selecting appropriate meals/fluids Monitoring nutritional status Monitoring fluid intake Assisting with eating and drinking Feeding dependent clients and clients with potential swallowing difficulties Chapter 6 Providing first aid to a client who is choking References and further reading Communicating Penelope Ann Hilton and Helen Taylor 159 Introduction Common terminology Assessing the communication needs of clients Responding to telephone calls Communicating with clients Managing violence and aggression Record keeping References and further reading Chapter 7 Dying Penelope Ann Hilton 178 Introduction Common terminology Assessing the dying client Communicating with dying clients and their relatives Signs of approaching death Confirming death Accounting for valuables Last Offices References and further reading Chapter 8 Eliminating Carol Pollard and Beverly Levy 199 Introduction Common terminology Assessing the individual’s ability to eliminate Assisting clients to use toileting facilities Applying/changing a nappy Care of an indwelling urinary catheter viii Fundamental Nursing Skills Monitoring urinary output Monitoring bowel actions Monitoring vomitus References and further reading Chapter 9 Maintaining body temperature Sheila Lees and Penelope Ann Hilton 225 Introduction Common terminology Normal body temperature Methods of temperature measurement Assessing an individual’s ability to maintain body temperature Monitoring temperature Recording and documenting body temperature Strategies to raise or lower body temperature References and further reading Chapter 10 Expressing sexuality Penelope Ann Hilton 239 Introduction Common terminology Assessing an individual’s ability to express sexuality Maintaining privacy and dignity Assisting individuals to express sexuality References and further reading Chapter 11 Working and playing Samantha Athorn and Penelope Ann Hilton 253 Introduction Common terminology Assessing an individual’s ability to work and play Assisting individuals to select appropriate work activities Assisting individuals to select appropriate recreational activities References and further reading ix Contents Chapter 12 Sleeping Penelope Ann Hilton 267 Introduction Common terminology Assessing an individual’s needs in relation to sleep and rest Monitoring an individual’s sleep and rest patterns Assisting individuals to achieve a balance between activity and rest References and further reading Appendix I Rapid reference aids Penelope Ann Hilton 277 Introduction NMC Code of Professional Conduct Guide to interpreting common medical and surgical terminology Glossary of medical and surgical terms Common medical and nursing abbreviations Common prescribing abbreviations Conversion tables Child development chart Body mass index Laboratory values Calculating infusion (drip) rates Calculating medications Appendix II Record of achievement Penelope Ann Hilton 306 Guidelines on the use of this record of achievement Skills related to the activity of breathing Skills related to the activity of mobility Skills related to the activity of personal cleansing and dressing Skills related to the activity of maintaining a safe environment Skills related to the activity of eating and drinking Skills related to the activity of communicating Skills related to the activity of dying Skills related to the activity of eliminating x Fundamental Nursing Skills Skills related to the activity of maintaining body temperature Skills related to the activity of expressing sexuality Skills related to the activity of working and playing Skills related to the activity of sleep and rest Additional skills Index 315 Acknowledgements First of all my eternal gratitude must be expressed to Rose for her unending perseverance and support. I would like to thank the many enlightened health care practitioners and students from the Royal Hallamshire Hospital, Sheffield, the Northern General Hospital, Sheffield and Chesterfield & North Derbyshire Royal Hospital, who contributed to the original research to verify the need for and content of such a text way back in 1994, and for their continued enthusiasm and input. I would also like to thank the many clients and relatives who shared their critical opinions; my colleagues whom I somehow managed to press-gang into authorship; the student nurses who very kindly passed judgement on the emerging chapters, not least Kerry Atkin, Emma Cornell, Fiona Maris; Sophie Kerslake for the brilliant illustrations; and Joanne Chilvers, Joint Course Leader for the Advanced Diploma in Nursing Studies programme at the University of Sheffield, for her critical reading of the final manuscript. xi Preface This book has arisen primarily in response to the increasing concern expressed about the perceived lack of ability in both students and newly qualified staff nurses to perform clinical skills. This deficit has been largely attributed to the advent of Project 2000 and the subsequent move of nurse education into Higher Education. Innovations in nursing such as the Nursing Process, Nursing Models and new methods of organizing care delivery, each with their emphasis on providing individualized nursing care, may also have exacerbated this problem. These initiatives have largely resulted in the demise of procedure manuals as a source of reference in many clinical areas. Consequently nurses and the increasing number of health care workers in new roles such as cadet nurses, health care assistants and generic ward practitioners no longer have an easily accessible source of reference in the clinical arena. This is particularly problematic when they are faced with undertaking a procedure for the first time. The intention of this book is to redress this deficit by: 1 outlining the elements of essential nursing procedures in a readily accessible format 2 providing the rationale for the recommended actions 3 promoting evidence-based practice. This book is unique in that it encourages the reader to keep a record of achievement in relation to clinical skill competence. It also differs from existing publications in that it is presented in a more readily accessible and user-friendly format for the busy clinician. Further, this text may be of benefit to lay persons undertaking the main carer role in the home setting. The selection of skills for inclusion is based on extensive consultation with experienced clinicians, students, clients and their significant others as well as teachers of nursing. Each procedure has been carefully researched to provide a contemporary foundation for practice. The book is the first of a series which aims to promote professional and personal xiii xiv Fundamental Nursing Skills development from novice through to expert in sequential stages. References and further reading are offered at the conclusion of each chapter. The inherent danger in producing books of this nature is that they may be perceived to be encouraging a task-orientated approach to patient care. In acknowledging this potential the chapters have been structured around the Activities of Living (Roper et al 2000) to encourage the reader to view each of the skills as an intricate part of holistic individualized care. The book also contains a rapid reference section of common terminology, conversion tables, laboratory results and other, equally useful, information. Whilst every attempt has been made throughout the text to reflect contemporary practices, the reader is reminded that practice will continue to develop in the light of new evidence and changing policy. A commitment to lifelong learning is therefore essential. Penelope Ann Hilton December 2003 Reference Roper N, Logan WW, Tierney A (2000) The Roper-Logan-Tierney Model of Nursing: The Activities of Living Model. Edinburgh: Churchill Livingstone. Contributors Samantha Athorn RGN, STH Movement and Handling Key Trainer, Practice and Professional Development Sister, Royal Hallamshire Hospital, Sheffield Julie Foster RN (Adult), DipN (Sheffield Hallam), Senior Staff Nurse, Gynaecological Directorate, Royal Hallamshire Hospital, Sheffield Penelope Ann Hilton SEN, SRN, RMN, DipN (Lond), FETC, BSc (Hons), MMedSci, RNT Lecturer in Nursing, University of Sheffield Alyson Hoyles RGN, SCM, DipN (Lond), PGCEA, RNT, BEd (Hons), MSc (Nursing) Nursing Lecturer, University of Sheffield Sheila Lees RGN, MMedSci, BA (Hons), RCNT, DipN (Lond), FETC Nursing Lecturer, University of Sheffield Beverly Levy MA, BSc (Hons), RGN, RCNT, Cert Ed (FE), RNT Nursing Lecturer, University of Sheffield Carol Pollard ONC, RGN, DipN (Lond), Cert Ed (FE), BA (Hons), MMedSci, RNT Nursing Lecturer, University of Sheffield Neal Seymour MA (Ed), BA (Hons), RSCN, RGN, RNT Lecturer/Practitioner, Sheffield Children’s Hospital/University of Sheffield Helen Taylor RGN, RMN, RNMH, BSc (Hons), MMedSci, RNT Nursing Lecturer, University of Sheffield Catherine Waskett RGN, BSc (Hons), MSc, ONC, Lecturer in Nursing, University of Sheffield xv Introduction In 1859 Florence Nightingale suggested that ‘The elements of nursing are all but unknown’. It could be argued that this statement remains true today: some groups maintain that nursing is about keeping clients clean and well nourished; others that it is about making clients feel safe; others focus purely on the psychological needs of clients; and yet others think that it is about carrying out physical tasks delegated by, but remaining under the auspices of, doctors (Hilton 1997). In looking back down the well-trodden path it can be seen that over the past 150 years or so nursing has slowly evolved from something that was considered essentially women’s work, which could be undertaken by any ‘good woman’, was largely concerned with caring for the sick, and with providing the best environment for nature to take its course, to being something that is very complex, skilled and sometimes highly technical, involving health education and promotion as well as meeting a wide variety of illness-related needs of clients. It is now an occupation that attracts both men and women whose pay constitutes more than a bottle of gin (Hilton 1997). Indeed, many now contend that nursing has reached the epitome, that long-strived-for goal of professional recognition (Clay 1987), as it now has an academic, secular training programme, a Code of Professional Conduct (see Appendix I) and its own regulating body, the Nurses and Midwives Council. It is a profession that is clearly distinct from medicine, where registered nurses are considered autonomous, accountable practitioners who work from a soundly researched knowledge base and whose practice is for the benefit of others. The majority of changes that have occurred in nursing and other emergent professions allied to medicine, such as physiotherapy and occupational therapy, have occurred as a result of changing health care needs, technological advances and a plethora of new knowledge as well as changes in societal attitudes, values and beliefs and an increasing cultural milieu. We now live in times of continuing change and advancement. xvii xviii Fundamental Nursing Skills Consequently health care, and therefore nursing, cannot remain a static entity. It must move, develop and evolve in the light of societal changes along with its other related disciplines. In order to enable effective response, to provide direction to influence health care policy and legislation, to assist in determining further workforce needs, and to inform resource management the Royal College of Nursing (RCN) has recently undertaken a scoping exercise. It defined nursing as ‘the use of clinical judgement and the provision of care to enable people to promote, improve, maintain or recover health or, when death is inevitable, to die peacefully’ (RCN 2003:1). This has come at a time when the current government is seeking to contain costs, destabilize the professions and merge professional boundaries with the ultimate aim of promoting better interprofessional working and, thus, higher standards and more cost-effective but better-quality health care. As such, a much greater emphasis is being placed on the promotion and maintenance of health and well-being. However, a word of caution: this definition advanced by the RCN, and the assumptions on which it is based, should not be viewed in isolation. As with many of the previous definitions of nursing offered and indeed the sometimes radical changes in nursing and health care that have taken place in recent years, to date there has been no client involvement in its conception or development. However, despite presenting a little background to nursing and health care today, it is not the purpose of this text to dwell on definitions of health and illness or to debate the politics of health care, but to provide practical direction in day-to-day clinical experiences. It would therefore seem prudent to reflect on current practice, part of which is about assessing client care needs. Assessment and the nursing process In order to determine a client’s care needs, assessment is a crucial first step. If a client’s normal routines, patterns and behaviours are not explored and compared with their current health care status and abilities, significant aspects of care need may be omitted or care may be provided that the client does not require. In doing so, there is a risk of jeopardizing their independence and losing their trust and confidence. Assessment is the first stage of a four-stage cyclical process generally referred to as the ‘Nursing Process’ (Yura and Walsh 1967), a concept developed in the USA during the early 1980s. The other three stages are planning, implementing, and evaluation, though other writers include data collection and diagnosis as separate stages. xix Introduction Whilst the emphasis appears to be on nursing, it can be argued that it is equally applicable to any profession claiming to provide a service and encountering a client for the first time. For those interested in exploring the historical development of this concept further, some key texts can be found at the end of this section. Assessment includes collecting all relevant information and then determining the client’s actual or potential problems. From this information care can then be planned in full consultation with the client, their significant others and other members of the multidisciplinary team as appropriate. Care planning should be clearly documented and include the goals of care – that is, what it is we are striving to achieve – making sure, of course, that these are both realistic and achievable, along with precise details of how they are going to be achieved. For example, Fred has been admitted to an acute medical setting with a very bad chest infection. On assessing his ability to breathe it is evident that he is experiencing difficulty expectorating his sputum; that is, he is unable to cough up the secretions from his lungs that are resulting from his infection. The goal of care may be that Fred will expectorate freely prior to discharge. The care then might include: • ensuring that Fred drinks a minimum of two litres of fluid per day • ensuring that he has a ready supply of sputum pots and tissues • referring him to the physiotherapist • providing chest percussion a least three times a day • instructing him in how to undertake deep breathing exercises to promote expectoration • ensuring that he undertakes these a minimum of three times a day prior to meals • providing mouthwashes every four hours and on request. Everyone involved in Fred’s care is therefore very clear about his care needs and can then go on to implement these without constantly having to check with Fred, the physiotherapist or other colleagues – provided of course that the instructions are clear and comprehensible (see the section on ‘Record keeping’ in Chapter 6). It is also useful to include measurements wherever possible as this can help us to evaluate whether or not Fred has achieved the desired goals of care later. xx Fundamental Nursing Skills The nursing process and nursing models Whilst the nursing process offers a systematic way of looking at care delivery, on its own it is not particularly useful as it does not give any indication as to what to assess. It indicates that care should be planned, implemented and evaluated but again offers little direction as to how to do this. Consequently a number of practitioners and nurse theorists have offered theoretical frameworks or models. One such model is the ‘Activities of Living Model’, proposed by Nancy Roper, Winifred Logan and Alison Tierney (1996). Basing their ideas on previous work by Maslow (1958) and Virginia Henderson (1960), and Nancy Roper herself, Roper, Logan and Tierney set out to describe what they believed everyday living involves for individuals, and from this identify the necessary components of nursing. In very simple terms their model can be summarized as consisting of four components, which all contribute to individuality in living, namely (1) the lifespan continuum from conception to death; (2) 12 activities of living (listed below); (3) five factors that influence each of these activities, that is physical, psychological, sociocultural, environmental and politicoeconomic; and (4) a dependence/independence continuum. The 12 activities of living are: 1 breathing 2 mobilizing 3 personal cleansing and dressing 4 maintaining a safe environment 5 eating and drinking 6 communicating 7 dying 8 eliminating 9 maintaining body temperature 10 expressing sexuality 11 working and playing 12 sleeping. According to Roper and her co-workers (2000), by assessing each of these aspects it is possible to determine a person’s individual nursing and health care needs and in doing so determine priorities of care. For example, when assessing an adult with an enduring mental health problem such as chronic depression, eating and drinking may be the priority of care, whereas if caring for a very young child, maintaining a safe environment might be the most urgent concern. xxi Introduction To return for a moment to Fred, clearly the illustration presented is of just one aspect of his care needs related to the physical side of the ‘activity of breathing’. In order to deliver holistic care (i.e. making sure that all his care needs are met), each factor of each activity must be assessed and his level of independence or dependence determined. So, for example, Fred may also be very anxious about not being able to expectorate his sputum and may think that if he cannot cough it out he will die. This illustrates how the activities, in reality, often overlap. By providing this simple framework, however, Roper, Logan and Tierney help to direct our thinking in a more logical, sequential way and if every aspect of each activity is covered when clients are assessed a clear picture of their individual needs should emerge without the omission of any important points. Whilst some might argue that Roper, Logan and Tierney’s model is not appropriate in caring for clients with learning difficulties or mental health problems, it is in fact the most widely used framework in Europe regardless of setting. If utilized to its fullest extent, it can usefully direct learners in any field of health care. Therefore, the remainder of this text is structured around their 12 activities of living to help readers to relate the theory to everyday practice. Each of the following 12 chapters offers: an introduction to the activity; common terminology related to that activity; points to consider when assessing the activity; followed by fundamental care skills related to that activity. Appendix I is a rapid reference section, which gives a detailed glossary to support the main text, normal values and other such useful information. Appendix II provides an opportunity for readers to record their achievements. Finally, as a point of note, whilst acknowledging the variety of terms in use, as well as possible gender issues, for ease and continuity the term ‘client’ has been used throughout this text. References and further reading Aggleton P, Chalmers H (2000) Nursing Models and Nursing Practice, 2nd edn. Basingstoke: Macmillan Press. Christenson P, Kenny J (1995) Nursing Process: Application of Conceptual Models. St Louis, MI: CV Mosby. Clay T (1987) Nurses, Power and Politics. London: Heinemann. Hawthorne DL, Yurkovich NJ (1995) Science, technology, caring and the professions: are they compatible? Journal of Advanced Nursing 21(6): 1087–1091. Henderson V (1960) Basic Principles of Nursing Care. London: ICN. Hilton PA (1997) Theoretical perspectives of nursing: a review of the literature. Journal of Advanced Nursing 26: 1211–1220. Marriner A (1979) The Nursing Process. St Louis, MI: CV Mosby. xxii Fundamental Nursing Skills Maslow A (1958) Hierarchy of Needs, cited in Maslow A (1968) Towards a Psychology of Being. New York: Rheinhold. Murphy K, Cooney A, Casey D, Connor M, O’Connor J, Dineen B (2000) The Roper, Logan and Tierney (1996) model: perceptions and operationalisation of the model in psychiatric nursing within a Health Board in Ireland. Journal of Advanced Nursing 31(6): 1333–1341. Nightingale F (1859) Notes on Nursing: What it is and what it is not. London: Duckworth (reprinted 1952). Nurses and Midwives Council (2002) Code of Professional Conduct. London: NMC. Roper N, Logan WW, Tierney A (1996) The Elements of Nursing, 4th edn. Edinburgh: Churchill Livingstone. Roper N, Logan WW, Tierney A (2000) The Roper-Logan-Tierney Model of Nursing: The Activities of Living Model. Edinburgh: Churchill Livingstone. Royal College of Nursing (2003) Defining Nursing. London: RCN. Thomas B, Hardy S (eds) (1997) Stuart and Sundeen’s Mental Health Nursing – Principles and Practice. St Louis, MI: CV Mosby. Wimpenny P (2002) The meaning of models of nursing to practising nurses. Journal of Advanced Nursing 40(3): 346–354. Yura H, Walsh M (1967) The Nursing Process. Norwalk, Connecticut: Appleton-Century-Crofts. Chapter 1 Breathing Penelope Ann Hilton Introduction The process of external respiration (breathing) consists of two stages, namely inspiration, inhaling (breathing in) air in order to extract the oxygen from the air, and expiration, exhaling (breathing out) in order to expel carbon dioxide. Oxygen is required by the body to release energy at cell level so that the individual can participate in activities. The release of such energy through metabolism produces carbon dioxide as a waste product that must be expelled from the body. The presence of carbon dioxide in the blood plays a key role in maintaining respiratory function and in maintaining homeostasis by regulating the pH of the blood (acid– base balance). A pH value between 7.35 and 7.45 is essential for normal body functioning. Breathing is essential to life. The ability to undertake a swift assessment of the client’s ability to breathe and instigate removal of an obstruction and/or rescue breathing if needed is therefore crucial (see ‘Maintenance of an airway’ and ‘Artificial respiration’). A full assessment of the person’s ability to breathe should be undertaken once adequate respiratory function has been restored. There are several important structural differences between adults and children that influence respiration, including the shape of the chest at birth, shape and angle of the ribs and elastic properties of the lung tissue. The nasal passages and trachea of infants and young children are narrower and can therefore be more easily obstructed. They also have less alveolar surface area for gaseous exchange. These latter points are extremely important when attempting to remove an obstruction or provide effective rescue breathing. It is, therefore, crucial to be familiar with the different techniques for these client groups. Factors that may affect breathing may be: • physical, arising from alteration in the structure, function or processes of the respiratory and associated systems • psychological, such as anxiety and stress • sociocultural, for example smoking 1 2 Fundamental Nursing Skills • environmental, including pollution and allergies • politico-economic, for example lack of finances for heating. The remainder of this chapter gives the common terminology associated with the activity of breathing, points to consider when assessing an individual’s breathing, how to monitor respiratory rate and peak flow, airway maintenance, monitoring of expectorant, obtaining specimens and disposing of sputum, administration of oxygen, and rescue breathing. The chapter concludes with references and further reading. Common terminology Aerobic With oxygen Anaerobic Without oxygen Anoxia No oxygen reaching the brain Apnoea Absence of breathing Apnoeustic breathing Prolonged gasping inspiration and short inefficient expiration Asthmatic breathing Difficulty on expiration with an audible expiratory wheeze. Caused by spasm of the respiratory passages and partial blockage by increased mucus secretion Biot’s respirations Periods of hyperpnoea occurring in normal respiration. Sometimes seen in clients with meningitis Bradypnoea Slow but regular breathing. Normal in sleep but may be a sign of opiate use, alcohol indulgence or brain tumour Cheyne-Stokes respirations Gradual cycle of increased rate and depth followed by gradual decrease with the pattern repeating every 45 seconds to three minutes. Also associated with periods of apnoea, particularly in the dying Cyanosis A bluish appearance of the skin and mucous membranes caused by inadequate oxygenation Dyspnoea Difficulty breathing Expiration The act of breathing out Haemoptysis Blood in the sputum Homeostasis The automatic self-regulation of man to maintain the normal state of the body under a variety of environmental conditions Hypercapnia High partial pressure of carbon dioxide Hyperpnoea Deep breathing with marked use of abdominal muscles Hyperventilation Increased rate and depth of breathing Hypoventilation Irregular, slow, shallow breathing 3 Breathing Hypoxia A lack of oxygen concentration Hypoxaemia A lack of oxygen in the blood Inspiration The act of breathing in Kussmaul’s respirations Increased respiratory rate (above 20 rpm), increased depth, panting laboured breathing. Causes include diabetic ketoacidosis and renal failure Orthopnoea The ability to breath easily only when in an upright position Perfusion The flow of oxygenated blood to the tissues Stridor A harsh, vibrating, shrill sound produced during respiration. Usually indicates an obstruction Tachypnoea Increased rate of breathing Tracheostomy Making of an opening into the trachea or windpipe Ventilation The movement of air in and out of the lungs Assessing an individual’s ability to breathe Remember that assessment of breathing is only part of a holistic nursing assessment and should not be undertaken in isolation without reference to or consideration of the client’s other activities of living. The specific points to be considered when assessing an individual’s breathing include: • Physical Respiratory rate depth sounds pattern/rhythm Presence of cough productive unproductive Sputum colour consistency amount smell Degree of effort, use of accessory muscles (e.g. shoulders/neck) Nasal flaring, which is usually a sign of increased effort, particularly in infants Sternal recession, the sinking in of sternum during inspiration, particularly in infants Tracheal tug, the sinking in of the soft tissues above the sternum and between the clavicles during inspiration, particularly in infants Intercostal recession, the sinking in of the soft tissues between the ribs during inspiration 4 Fundamental Nursing Skills Facial expressions Colour of skin/mucous membranes – mottling, pallor, cyanosis Presence of scars Shape of thorax, symmetry of movement Evidence of external/internal injury Position adopted by client and influence of body position on breathing Pain related to inspiration/expiration/movement Breathes through mouth and/or nose Clubbing of finger ends Head bobbing, that is, forward movement of head on inspiration in a sleeping or exhausted infant is a sign of breathing difficulty Status of hypoxic drive, that is, is the client retaining carbon dioxide? • Psychological Stress Anxiety Depression Hysteria Irritability Confusion • Sociocultural Level of support from family/external agencies Smoking Health beliefs/values Hobbies/pastimes Level of family support • Environmental Pollution, such as dust mites and pollen Cold, damp or foggy weather Type of accommodation Stairs to climb Work related • Politico-economic Limited finances Employed/unemployed Poor heating Poor diet • Past history Past illnesses related/unrelated Recent holiday abroad Family difficulties Powers of recovery Knowledge of condition 5 Breathing Monitoring respiratory rate