Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Indicators for Immediate Medical Attention

The following criteria should be assessed and supplemented by spriometry, if available (BTS/SIGN, 2003; NZGG, 2002; SIGN, 1999):

  • Respiration rate greater than 25 breaths/min;
  • Pulse greater than 110 beats/min;
  • Accessory muscle use;
  • Unable to complete a sentence between breaths;
  • Person is distressed (fatigue, exhaustion) and agitated (if person says they are in trouble or anxious, or Have an impending sense of doom);
  • Confusion; and
  • Altered level of consciousness.
If the client exhibits any one of the above symptoms, then they should be referred for immediate medical attention.