Breathing changes
Increased respiratory rate, increased effort, breathlessness, reduced oxygen saturation or a change in breathing pattern may be important warning signs.
NurseNet Clinical Skills
Recognising the Deteriorating Patient
Learn how to recognise early signs that a patient's condition may be worsening, assess them systematically and escalate concerns clearly and promptly.
Recognise. Assess. Escalate.
01
Notice change
Look for subtle as well as obvious deterioration.
02
Check observations
Compare current findings with the patient's baseline.
03
Use ABCDE
Assess the patient in a structured way.
04
Use NEWS2
Support recognition of physiological deterioration.
05
Escalate early
Seek appropriate clinical support when concerned.
Early recognition matters
Deterioration does not always begin dramatically.
A deteriorating patient is someone whose clinical condition is becoming worse. Sometimes this is obvious. At other times, the first warning signs are subtle changes in breathing, behaviour, observations or overall appearance.
Student nurses are often in a valuable position to notice these changes because they spend time observing, communicating with and providing care for patients.
You are not expected to diagnose the cause of deterioration. Your responsibility is to recognise concerning changes, gather relevant information and seek appropriate support.
If you are worried about a patient, that concern matters. Do not wait
for every observation to become abnormal before asking for help.
Warning signs
What might deterioration look like?
Changes can occur across several body systems. The wider pattern is often more useful than focusing on one isolated observation.
Circulatory changes
Changes in pulse, blood pressure, skin colour, temperature or peripheral perfusion may indicate worsening clinical status.
Consciousness
New confusion, agitation, drowsiness or reduced responsiveness can be significant and should not be dismissed.
Urine output
A new reduction in urine output may contribute to the picture of a patient whose condition is changing.
Pain or distress
New, severe or rapidly worsening pain can be clinically important, especially when accompanied by other changes.
Your overall impression
A patient may simply look or behave differently. Clinical concern based on a change from normal should always be taken seriously.
A systematic response
What should you do when you are concerned?
Your precise actions will depend on the patient's condition, your level of competence and the escalation policy in your clinical area.
1
Look at the patient
Assess their overall appearance, breathing, colour, behaviour, responsiveness and level of distress.
2
Check the observations
Obtain or review relevant vital signs and compare them with previous readings where available.
3
Use an ABCDE assessment
A structured ABCDE approach can help identify immediate problems and prevent important findings from being overlooked.
4
Review NEWS2 where appropriate
Use the local NEWS2 process to support recognition of physiological deterioration and required escalation.
5
Escalate clearly
Tell the appropriate clinician what has changed, why you are concerned and what your assessment has shown.
6
Reassess
Continue monitoring as directed and look for further improvement or deterioration after interventions or clinical review.
Look for trends
Change over time can be more important than one number.
A patient's observations should be interpreted in context and compared with their previous condition whenever possible.
Compare with baseline
Ask whether the patient's current observations, behaviour and symptoms are different from their usual state.
Look across observations
Several small changes occurring together may create a more concerning picture than one reading considered alone.
Listen to the patient
Patients may tell you that they feel significantly worse before an obvious physiological change becomes apparent.
Listen to those who know them
Relatives, carers and staff familiar with the patient may recognise important changes in behaviour or function.
Escalation
Communicate the concern, not just the numbers.
Good escalation gives the receiving clinician enough information to understand why the patient needs review.
- Identify the patient clearly.
- State immediately that you are concerned.
- Explain what has changed.
- Give relevant observations and NEWS2 information.
- Summarise important ABCDE findings.
- Explain any actions already taken.
- Ask clearly for the review or support you need.
Structured communication such as SBAR can help you organise this
information clearly when escalating or handing over a deteriorating patient.
Patient safety
Never delay escalation because you are βonly a studentβ.
Student nurses are not expected to manage a deteriorating patient independently, but they are expected to raise concerns and seek help.
If you think the patient is getting worse, speak up.
Follow the escalation procedure in your placement area and involve an appropriately qualified member of staff promptly. If your concern remains unresolved and the patient continues to deteriorate, continue to escalate according to local policy.
Student nurse focus
How to become better at spotting deterioration
Confidence develops when you connect individual clinical skills rather than treating them as separate tasks.
- Compare current vital signs with previous observations.
- Practise ABCDE assessments during simulation and supervised care.
- Understand how NEWS2 is used in your placement area.
- Ask experienced nurses what changes make them concerned.
- Practise escalating a concern using SBAR.
- Reflect on occasions where a patient's condition changed.
The goal is not to diagnose the problem yourself. The goal is to notice
that something may be wrong and help the patient receive appropriate
assessment quickly.
Next clinical skill
Next: SBAR communication.
Once you recognise deterioration, the next essential skill is being able to communicate that concern clearly to the right person.
Continue to SBAR