How to be a better nurse in 60 seconds.

If you want to be a better nurse just do this one thing:


In a paper titled: Accurate respiratory rates count: So should you!, Tracy Flenady et al, looked at the reasons why our patients respiratory rates are the least accurately documented of all the vital signs we do.

Historically the reasons that nurses have given for shabby documentation of accurate respiratory rates includes:

  • Workload and time constraints.
  • Interruptions to workflow.

Current beliefs regarding respiratory rates:

The authors decided to dig a little deeper into this and collected data from seventy nine emergency departments in Australia.

The result was that the overall belief of the nurses in this study was that:

“counting respiratory rates at each round of observations is superfluous to patients’ needs and wastes valuable time. Even more illuminating, results from this grounded theory study reveal that often, these nurses believe they are enhancing patients’ outcomes by performing tasks other than counting respiratory rates. ”

Nurses felt that recording an accurate respiratory rate only a priority in patients currently in respiratory distress, or paediatric patients or patients with a clear existing respiratory illness.

Of note the study found: “that more often than not, a value was entered on the observation chart without the respiratory rate being assessed at all.”

We all know this. Radar obs, psychic obs, ghost obs, guesstimations, call them what you will…what they actually are is a form of fraud.


Why Respiratory Rate is VITAL!

The normal respiratory rate for an non-compromised adult at rest is 12–20 breaths per minute. This maintains the optimum clearance via the lungs, of carbon dioxide that has been produced in the blood.

“Physiologically, it is essential to understand that a shift in alveolar ventilation, manifested in either an increase or decrease in the respiratory rate, is one of the body’s methods of striving for homeostasis, and can be an important sign of clinical decline. It is significant to note, that the respiratory rate provides more discriminating evidence of clinical decline in seemingly stable patients, than other vital signs”

  • 4 breaths per minute either side of normal range can indicate signs of serious clinical deterioration.
  • a respiratory rate of 8 or less may indicate imminent medical emergency (and these patients may have up to 18 times more likelihood of death within 24hrs than a patient with normal resps.)




How to evaluate respiratory rate.

Accurate respiratory rates can be monitored via continuous methods such as capnography or via the discontinuous method of counting the respiratory rate.

Best practice guidelines recommend counting the patients respiratory rate over a full minute, whilst also noting and abnormalities in depth, rhythm, sound and effectiveness.

The authors also note that in order to avoid erroneous rates due to the patient being aware that you are counting there resps, you should try to do it ‘surreptitiously’. One way to do this is to hold the patients wrist as if counting their pulse. Or you can simply stand back and be covert.


The authors conclude:

“Results from this same study reveal that the respiratory rate is the second most sensitive vital sign, after saturation of peripheral oxygen as a predictor of in hospital mortality. When evidence such as this is considered, it becomes clear that when nurses just ‘tick and flick’ a patient’s respiratory rate in order to use their time more wisely to improve patients’ outcomes, they could in fact be doing the complete opposite.”


  1. Flenady, Tracy, Trudy Dwyer, and Judith Applegarth. “Accurate respiratory rates count: So should you!” Australasian Emergency Nursing Journal 20, no. 1 (2017): 45–47. doi:10.1016/j.aenj.2016.12.003.

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