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Recognising & Responding to Patient Deterioration

Recognising Respiratory Deterioration for Student Nurses

Learn how to recognise changes in breathing, assess respiratory deterioration systematically and escalate concerns promptly and safely during clinical placement.

Patient safety priority: respiratory deterioration can become life-threatening quickly. If a patient has severe breathing difficulty, airway compromise, rapidly worsening oxygenation or another significant clinical change, obtain registered help immediately and follow your local emergency escalation procedure.
Understanding deterioration

What is respiratory deterioration?

Respiratory deterioration occurs when a patient's ability to breathe effectively or maintain adequate oxygenation is worsening. It may develop suddenly or progress over a period of time.

The earliest warning is not always a dramatic fall in oxygen saturation. Changes in respiratory rate, work of breathing, behaviour, speech or overall appearance may become apparent first.

As a student nurse, you are not expected to diagnose the underlying respiratory condition independently. Your role is to recognise concerning changes, assess within your competence and communicate those findings promptly to an appropriate registered practitioner.

Think trend, not just numbers. Compare current observations with previous results and the patient's usual baseline. A significant change may be clinically important even when a single observation does not appear extreme.
Early recognition

Signs that breathing may be deteriorating

Breathing pattern

  • Increasing respiratory rate
  • Very slow respiratory rate
  • Shallow breathing
  • Irregular breathing
  • Visible increase in respiratory effort

Oxygenation

  • Falling oxygen saturation
  • Increasing oxygen requirement
  • Cyanosis or abnormal skin colour
  • Restlessness or confusion
  • Reduced responsiveness in severe deterioration

Patient appearance

  • Unable to speak comfortably
  • Use of accessory muscles
  • Difficulty lying flat
  • Exhaustion or increasing fatigue
  • Anxiety or obvious respiratory distress
Severe respiratory distress is an emergency. A patient who is struggling to breathe, becoming exhausted, showing signs of airway compromise or becoming less responsive requires immediate escalation according to local emergency procedures.
Respiratory rate

Why respiratory rate matters

Respiratory rate is an important physiological observation and may change early when a patient deteriorates.

A rising respiratory rate may occur when the body is attempting to compensate for respiratory, cardiovascular, metabolic or systemic illness. An abnormally slow rate can also be concerning, particularly when accompanied by reduced consciousness or other signs of deterioration.

Measure rather than estimate. Respiratory rate should be counted accurately according to your local observation procedure. If a reading is unexpected, reassess it and seek guidance rather than automatically assuming that it is an error.
Oxygen saturation

Interpret SpOā‚‚ in the clinical context

Pulse oximetry provides useful information about oxygen saturation, but the number should never be interpreted in isolation.

Consider whether the reading fits with the patient's appearance, respiratory rate, prescribed oxygen target, oxygen therapy and previous observations.

When a reading looks unexpected

  • Check that the probe is positioned appropriately.
  • Consider movement or poor peripheral perfusion.
  • Check whether the displayed pulse corresponds with the patient.
  • Repeat the observation where appropriate.
  • Do not delay escalation if the patient looks clinically unwell.
Important: some patients have individually prescribed oxygen saturation targets. Always follow the patient's documented target and your local oxygen and NEWS2 policies rather than assuming the same target is appropriate for everyone.
ABCDE assessment

Assess respiratory deterioration systematically

When a patient appears acutely unwell, the ABCDE approach helps structure assessment and ensures that immediate threats to life are prioritised.

A

Airway

Check whether the airway appears patent. Can the patient speak? Listen for abnormal airway sounds and obtain immediate help if airway obstruction is suspected.

B

Breathing

Assess respiratory rate, oxygen saturation, work of breathing, chest movement and other appropriate respiratory findings within your competence.

C

Circulation

Consider pulse, blood pressure, skin appearance and perfusion. Respiratory deterioration may occur alongside circulatory compromise.

D

Disability

Look for confusion, agitation, drowsiness or reduced responsiveness, which may accompany significant deterioration.

E

Exposure

Look for additional clinical clues while maintaining privacy and dignity. Consider temperature and other relevant findings according to the clinical situation.

Look, listen and measure

What should you notice at the bedside?

Observation What you might notice Why it matters
Respiratory rate Increasing, decreasing or irregular rate May indicate changing respiratory or physiological status.
Work of breathing Accessory muscle use, visible effort or exhaustion May indicate that breathing is becoming increasingly difficult.
Speech Unable to complete normal sentences comfortably Can be a practical sign of significant breathlessness.
SpOā‚‚ Falling saturation or increasing oxygen requirement Requires interpretation against target range and clinical condition.
Conscious level Restlessness, confusion, drowsiness or reduced response Neurological change may accompany severe respiratory deterioration.
Overall appearance Pale, clammy, cyanosed, distressed or exhausted The patient's appearance may communicate urgency before all results are available.
NEWS2

Respiratory observations are central to NEWS2

NEWS2 incorporates respiratory rate and oxygen saturation alongside other physiological observations. Supplemental oxygen is also considered within the NEWS2 assessment.

A change in respiratory observations can therefore contribute significantly to an increasing NEWS2 score and trigger escalation under local policy.

Clinical judgement still matters. Do not wait for a particular NEWS2 total if the patient is visibly struggling to breathe or their clinical condition is causing concern.
Escalation

What should you do when breathing deteriorates?

1

Recognise the change

Compare the patient's breathing, observations and clinical appearance with their previous condition and baseline.

2

Stay with an acutely unwell patient

Where appropriate, remain with a patient who appears unstable while assistance is obtained.

3

Call the registered nurse

Tell the nurse responsible for the patient, your practice supervisor or another appropriate registered clinician promptly.

4

Communicate specific findings

Give the respiratory rate, oxygen saturation, oxygen therapy where relevant, NEWS2 and important changes in the patient's appearance or conscious level.

5

Follow the local escalation pathway

Follow your organisation's deterioration, oxygen and emergency response policies. Escalate further if the patient continues to worsen or your concern remains unresolved.

Communication

Use SBAR to make respiratory concerns clear

Example scenario

A patient who was comfortable earlier in the shift is now visibly breathless. Their respiratory rate has risen from 18 to 30 and their oxygen saturation has fallen compared with their previous observations.

"I'm concerned about Mr Harris in bed four. He has become significantly more breathless. His respiratory rate has increased from 18 to 30 and his oxygen saturation has fallen from his earlier reading. He looks distressed and is struggling to speak normally. Could you review him now, please?"

Clear communication describes the change and makes the urgency obvious without requiring you to independently diagnose the cause.

Oxygen safety

Understand your role around oxygen therapy

Oxygen is a medication and its use should follow the patient's clinical requirements, prescription or emergency protocol and your organisation's local policy.

As a student nurse, you should know where to find the patient's prescribed target saturation range and understand how to report oxygen therapy accurately when escalating.

Scope of practice: do not independently commence, alter or discontinue oxygen therapy unless this is appropriate within your assessed competence, supervision arrangements and local emergency policy. If a patient is acutely deteriorating, obtain registered clinical help without delay.
Common mistakes

What can delay recognition?

Focusing only on SpOā‚‚

A patient may be deteriorating despite an apparently acceptable saturation. Respiratory rate and clinical appearance matter.

Estimating respiratory rate

An inaccurate respiratory rate can hide an important trend. Measure it according to local procedure.

Ignoring increasing effort

A patient who is working increasingly hard to breathe may be deteriorating even before other observations change markedly.

Waiting for severe cyanosis

Do not wait for dramatic late signs before escalating a patient whose breathing is worsening.

Assuming anxiety is the cause

Restlessness or anxiety can accompany physiological deterioration. Assess the patient rather than dismissing it.

Waiting for certainty

You do not need to diagnose the respiratory problem before asking a registered practitioner to review the patient.

Reassessment

Respiratory deterioration is dynamic

Assessment is not a one-off event. A patient's condition can change quickly, particularly during acute illness.

Repeat observations according to the patient's condition, clinical plan and local escalation policy. Report further deterioration promptly rather than assuming that an earlier escalation remains sufficient.

If the patient worsens, escalate again. Increasing respiratory distress, worsening observations, exhaustion or reduced responsiveness should trigger further urgent assessment according to local procedures.

Respiratory deterioration checklist

  • Has the respiratory rate changed?
  • Has oxygen saturation changed from the patient's baseline?
  • Does the patient have a prescribed oxygen target range?
  • Is the patient receiving oxygen, and has the requirement changed?
  • Is breathing visibly more difficult?
  • Can the patient speak comfortably?
  • Are they becoming tired or exhausted?
  • Is there new confusion, restlessness or drowsiness?
  • Has NEWS2 changed?
  • Have I escalated the concern appropriately?
Professional practice

Your role as a student nurse

Recognising respiratory deterioration is an important patient-safety skill. The NMC Code emphasises preserving safety, communicating effectively and acting without delay when patient safety may be at risk.

Students should develop confidence in observing patients, recognising changes and reporting concerns while remaining within their level of competence and using appropriate supervision.

Learning reminder: this resource supports education and revision. It does not replace university teaching, clinical supervision, current national guidance or your NHS trust, health board or placement provider's local respiratory deterioration, oxygen and emergency policies.

Key takeaway

Respiratory deterioration may first appear as a change in respiratory rate, work of breathing, oxygen saturation, speech, behaviour or overall clinical appearance.

Look at the whole patient, compare observations with previous results, use ABCDE and NEWS2 appropriately and communicate concerning changes promptly.

If you are worried about a patient's breathing, escalate. Always follow local policy, work within your scope of practice and competence, and seek appropriate supervision from registered practitioners.