What to Do When the Assessment Is Abnormal but the Vital Signs Are Not
One of the hardest things to trust as a new nurse is an assessment that does not match the vital signs. You walk out of the room knowing something has changed, but the heart rate is 88, the blood pressure is 116/74, the oxygen saturation is 97% on room air, and the temperature is 98.6°F. Nothing on the monitor explains why the patient’s skin looks different, why they are answering more slowly, or why they have become quieter than they were an hour ago.
Because none of the numbers are alarming, you start talking yourself out of what you noticed. Maybe you are reading too much into it. Maybe the patient is tired. Maybe you should wait for the next set of vitals and see what happens.
I see this often with nursing students and new nurses. They recognize that something is different, but they do not feel like they have enough information to speak up. They are waiting for one abnormal number to confirm what the rest of the assessment is already telling them.
Vital Signs Need Context
Vital signs are an important part of the assessment, but a number that falls within the expected range does not automatically mean the patient is stable. Some patients can maintain their blood pressure during the early stages of volume loss or another developing perfusion problem. Others may not produce the physiological response you expected because of their medications, age, medical history, or baseline vital signs.
A patient taking a beta blocker may not become as tachycardic as you anticipated. A blood pressure of 118/70 may look completely normal until you learn that the patient usually runs around 170/95. An older adult may have a less obvious response to infection or volume loss, while a healthy younger patient may maintain a normal blood pressure despite a significant change in circulating volume.
Timing matters too. One set of vital signs tells you what was happening at that moment. Looking at several sets together may show a heart rate slowly climbing, a blood pressure gradually decreasing, or a respiratory rate that has changed even though none of the individual readings crossed a critical threshold.
The question is not only whether the vital signs are normal. You also need to ask whether they are normal for this patient and whether they are moving in the wrong direction.
Look at What Is Happening Around the Numbers
When a patient is beginning to deteriorate, the first clue may come from the hands-on assessment. Cool or diaphoretic skin, delayed capillary refill, weaker peripheral pulses, or new mottling may suggest a change in peripheral perfusion. None of these findings gives you a diagnosis by itself, but they deserve attention when they are new or appear together.
Mental status changes may also be subtle. The patient may still be oriented, but they are taking longer to answer you. They may seem restless, unusually quiet, or less engaged than they were earlier. When a family member tells you the patient is not acting like themselves, include that in your assessment. They know what is normal for that patient and may recognize a change before anyone else does.
Respiratory effort is another place where the monitor can give you an incomplete picture. A patient can maintain an oxygen saturation of 96% while working much harder to breathe. Count the respiratory rate yourself and look at the depth of breathing, positioning, accessory muscle use, ability to finish a sentence, and whether the patient appears to be tiring.
Urine output can add another piece to the picture, especially when it is decreasing along with other changes in perfusion. Review how much urine the patient has produced, over what period of time, and what else may be affecting it. Renal history, medications, intake, an obstruction, and the overall clinical presentation all matter.
Any one of these findings may have several explanations. What should get your attention is the change from the patient’s earlier assessment and the pattern that begins to form when you put the findings together.
Put the Concern Into Words
“Something feels off” is often where pattern recognition starts. You may not be able to explain it immediately, but that feeling should prompt you to go back to the bedside and look more closely. The next step is turning that concern into objective findings that you can communicate.
This is where I use the Clinical Why questions:
What is it? Name what you found instead of stopping at “the patient does not look right.” Their skin is cool and damp, their capillary refill is four seconds, and they are answering more slowly than they were during the previous assessment.
Why do we care? Think about what those findings may represent. Could perfusion, oxygenation, neurological status, or another part of the patient’s condition be changing?
What should I watch for? Decide what needs to be trended or reassessed. That may include the heart rate, blood pressure, pulse pressure, respiratory rate, mental status, skin findings, pain, and urine output.
What should I do about it? Verify the information, widen the assessment, involve another nurse when needed, and escalate the concern based on the patient’s presentation and your facility’s process.
What happens if I miss it? Consider what may happen if the change continues and no one intervenes. This helps you decide how urgently the concern needs to be communicated.
Go Back and Reassess
Start by verifying the vital signs. Make sure the blood pressure cuff is the correct size and positioned properly. Repeat the measurement manually when appropriate, palpate the pulse, and count the respirations yourself. You are checking whether the information is accurate and whether it fits the patient in front of you.
Next, review the trend. A heart rate that has increased from 68 to 88 to 104 over three hours tells you more than the current reading by itself. The same applies to a gradually decreasing blood pressure, increasing respiratory rate, worsening oxygen requirement, or change in mental status.
Return to the bedside and widen the assessment based on what you are seeing. Reassess the lungs, abdomen, pulses, skin, pain, mental status, urine output, and any relevant dressings, incisions, injured extremities, or access sites. Review recent medications, procedures, fluids, and other interventions that may explain the change.
Nurses do not make medical diagnoses, but we should be able to recognize patterns and consider what the patient may be presenting with. Bleeding, infection, hypoxia, an adverse medication effect, or an obstruction may be on your list of concerns. Thinking through those possibilities helps you decide what needs immediate attention and what labs, imaging, medications, or other interventions you may need to anticipate.
If the findings still concern you, ask an experienced nurse or charge nurse to assess the patient with you. Nurses do this for each other all the time. Sometimes another person confirms what you are seeing. Sometimes they notice a finding you had not connected yet. Either way, you have more information to use when you escalate.
You Can Escalate Without a Critical Number
New nurses often feel like they need a heart rate of 140 or a blood pressure of 70/40 before they have enough information to call. Waiting for a critical number can delay the assessment and treatment of a patient who is already changing.
When you call, give the objective findings, explain what has changed, and make a clear request. For example:
“Dr. Rivera, this is Francisca calling about Mr. Alvarez in room 12. He came in with abdominal pain. His current vital signs are within the expected range, but his skin is now cool and diaphoretic, his capillary refill is four seconds, and his heart rate has increased from 68 to 104 over the last three hours. He has had 30 mL of urine output in four hours. I am concerned about worsening perfusion and possible clinical deterioration. I need you to assess him now, and I anticipate he may need repeat labs and further evaluation.”
You did not diagnose the patient. You described what you found, identified the pattern that concerns you, and communicated what you need next. If the response does not match the urgency of the situation, continue through the appropriate escalation process. Depending on your setting, that may involve the charge nurse, another provider, a rapid response team, or the chain of command.
Research supports what experienced nurses have recognized at the bedside for years. Nursing concern can be present before vital signs meet established escalation criteria. A systematic review found that nurse worry may occur with or without a change in vital signs, and a prospective study found that higher nurse worry scores were strongly associated with ICU transfer within 24 hours. More recent research describes nurse worry as a process that involves recognizing and connecting clinical cues, changes, and patterns rather than relying on a feeling alone (Douw et al., 2015; Romero-Brufau et al., 2019; Byrne et al., 2025).
The Society of Critical Care Medicine also recommends that hospitals have rapid response systems with clear activation criteria and that concerns from patients, families, and care partners be included when deciding whether additional help is needed. Your facility’s specific escalation policy should guide who you call and how quickly you move through the chain of command (Honarmand et al., 2024).
Document the Change
Document what you found, how it compared with the previous assessment, the vital sign trend, who you notified, what you communicated, and the response you received. Keep the language objective.
Instead of writing that the patient “appears unwell,” document that the patient’s skin is cool and diaphoretic, capillary refill is four seconds, and responses are slower than during the previous assessment. That gives the next nurse something specific to compare with their own findings and creates a clear timeline of the change.
An assessment matters because it can identify a problem before the monitor does. When the vital signs do not explain what you are seeing, go back to the patient, verify the information, look at the trend, and put the concern into words. Do not wait for one number to give you permission to act.
Download the Free Guide
I created Think Like an Experienced Nurse for the part of nursing that is harder to learn from a checklist: connecting the findings, deciding what needs to happen next, and explaining why you are concerned.
Download the free guide at nurserootedco.com/free-guide.
References
Byrne, A.-L., Massey, D., Flenady, T., Connor, J., Chua, W. L., & Le Lagadec, D. (2025). When nurses worry: A concept analysis of intuition in clinical deterioration. Journal of Advanced Nursing, 81(8), 4566–4583. https://doi.org/10.1111/jan.16956
Douw, G., Schoonhoven, L., Holwerda, T., Huisman-de Waal, G., van Zanten, A. R. H., van Achterberg, T., & van der Hoeven, J. G. (2015). Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: A systematic review. Critical Care, 19, Article 230. https://doi.org/10.1186/s13054-015-0950-5
Honarmand, K., Wax, R. S., Penoyer, D., et al. (2024). Society of Critical Care Medicine guidelines on recognizing and responding to clinical deterioration outside the ICU: 2023. Critical Care Medicine, 52(2), 314–330. https://doi.org/10.1097/CCM.0000000000006072
Romero-Brufau, S., Gaines, K., Nicolas, C. T., Johnson, M. G., Hickman, J., & Huddleston, J. M. (2019). The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. JAMIA Open, 2(4), 465–470. https://doi.org/10.1093/jamiaopen/ooz033
Disclaimer
For educational purposes only. Always practice within your legal scope and follow your facility’s policies, procedures, and escalation protocols.
