Respiratory rate
The number of breaths taken per minute. Observe the rate as well as breathing depth, pattern, effort and any signs of respiratory distress.
NurseNet Clinical Skills
How to Take and Record Vital Signs
Vital signs are a fundamental part of patient assessment. Learn what each observation tells you, how to record findings accurately and why recognising changes can be just as important as the individual numbers.
Core observations
01
Respiratory rate
Breathing frequency and pattern
02
Oxygen saturation
Peripheral oxygen measurement
03
Blood pressure
Circulatory pressure
04
Pulse
Rate, rhythm and quality
05
Temperature
Body temperature measurement
Why observations matter
Vital signs help you build a picture of the patient.
A set of observations is more than a collection of numbers. Vital signs provide information about how a patient's respiratory, cardiovascular and physiological systems are functioning at that moment in time.
Observations become particularly useful when they are considered alongside the patient's appearance, symptoms, clinical history and previous readings.
Student nurses should develop the habit of asking two questions: Does this result make sense? and Has anything changed?
A result does not have to look dramatically abnormal to matter.
A change from a patient's previous observations may be clinically
significant and should never be ignored.
The core observations
What are the main vital signs?
The exact observations required will depend on the patient, clinical setting and local policy, but these are among the measurements student nurses encounter most frequently.
Oxygen saturation
Pulse oximetry estimates peripheral oxygen saturation. Interpret the reading in context and be alert to factors that can affect accuracy.
Blood pressure
Blood pressure provides information about the pressure within the arterial circulation and should be interpreted alongside the patient's overall condition.
Pulse
Assess pulse rate and, where appropriate, rhythm and strength. Consider whether the result is consistent with the patient's presentation.
Temperature
Temperature measurement can contribute to identifying infection, inflammation, environmental exposure and other physiological changes.
Level of consciousness
Changes in alertness or responsiveness can be an important sign of deterioration and may form part of structured observation systems.
A safe approach
Taking a set of observations
Always follow the equipment guidance, local policy and supervision requirements in your placement area. A consistent approach helps reduce errors and makes it easier to recognise unexpected results.
1
Identify the patient correctly
Follow local identification procedures and explain what you are going to do before beginning the assessment.
2
Observe before you measure
Look at the patient. Notice their breathing, colour, behaviour, position, comfort and whether they appear acutely unwell.
3
Use the equipment correctly
Check that equipment is appropriate, functioning correctly and used according to training and local guidance.
4
Check unexpected readings
If a result seems inconsistent with the patient's condition, consider possible measurement error and repeat or verify it appropriately.
5
Record promptly and accurately
Document the observation in the correct place and avoid relying on memory or recording results later.
6
Escalate concerns
If you are concerned about the patient or the observations, seek support promptly and follow the escalation process used in your clinical area.
Interpretation
Don't assess a number in isolation.
Reference ranges can help you recognise potentially abnormal findings, but clinical assessment should always consider the individual patient, their baseline observations and the wider clinical picture.
| Observation | What to consider | Useful student habit |
|---|---|---|
| Respiratory rate | Rate, depth, effort, pattern, breath sounds and distress. | Count carefully rather than estimating. |
| Oxygen saturation | Reading, oxygen therapy, target range and reliability of signal. | Check the patient as well as the monitor. |
| Blood pressure | Current result, previous readings, symptoms and measurement technique. | Use the correct cuff and positioning. |
| Pulse | Rate, regularity, strength and relationship to other observations. | Notice whether the pulse feels regular. |
| Temperature | Measurement method, trend, symptoms and environmental factors. | Use a consistent approved technique. |
| Consciousness | Alertness, new confusion, response and change from normal behaviour. | Treat a new change as important. |
Recognising deterioration
Look for trends and changes.
One of the most important skills you can develop is recognising when a patient's observations or overall presentation are changing.
If the patient looks unwell, act on your concern.
Do not wait for every observation to become abnormal before seeking help. Clinical concern itself matters. Follow local escalation procedures and involve an appropriately qualified member of staff.
- Compare current observations with previous readings where available.
- Notice whether several observations are changing at the same time.
- Consider the patient's symptoms and appearance alongside the numbers.
- Repeat an unexpected measurement when appropriate and safe to do so.
- Report concerns clearly and promptly.
- Know how your placement area escalates deteriorating patients.
Documentation
Recording observations accurately
Accurate documentation allows other members of the healthcare team to see the patient's current condition and recognise changes over time.
Record the actual result
Enter the observation accurately in the approved chart or electronic record. Do not alter a result simply because it is unexpected.
Record at the correct time
Prompt documentation reduces the risk of forgotten, delayed or incorrectly attributed observations.
Include relevant context
Where required, record information such as oxygen therapy, patient position or other factors that affect interpretation.
Document escalation
Follow local policy for documenting concerns, actions taken, communication and any subsequent reassessment.
Student nurse focus
How to become more confident with observations
Confidence develops through repetition, feedback and understanding what the observations actually mean. Try not to treat taking observations as a task to complete as quickly as possible.
- Practise a consistent sequence when taking observations.
- Ask your supervisor to check your technique.
- Look at previous observations before interpreting new results.
- Ask why a particular patient requires more frequent monitoring.
- Learn how observations contribute to NEWS2 in your clinical area.
- Practise communicating an abnormal finding clearly and concisely.
The aim is not simply to become faster at taking observations.
The aim is to become better at noticing what those observations are
telling you about the patient.
Next clinical skill
Next: understand NEWS2.
Once you're comfortable with individual observations, the next step is understanding how they are brought together to help identify possible deterioration.
Continue to NEWS2