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Recognising a Deteriorating Patient Early

Many patients show signs of deterioration before their condition becomes a critical emergency. Sometimes the change is obvious, such as severe breathlessness or reduced consciousness. At other times it is much less dramatic: new confusion, unusual tiredness, pale or clammy skin, a change in behaviour or simply the sense that the person is not as they normally are.

Knowing how to recognise a deteriorating patient means noticing those changes early, assessing what is happening in a structured way and escalating concerns before the patient’s condition worsens further. That matters in hospitals, GP surgeries, dental practices, community clinics and care environments, where the people, equipment and immediate support available may be very different.

The aim is not to make a diagnosis before asking for help. It is to recognise that the patient is becoming more unwell, identify immediate problems, begin appropriate care within your role and make sure the right level of support is involved early enough.

What are the early signs of a deteriorating patient?

There is no single sign that identifies every deteriorating patient. A change in breathing, circulation, consciousness, behaviour, temperature or general appearance may all be important. Often, it is the combination of several small changes or the direction in which observations are moving that tells the clearer story.

Warning signs can include:

  • Increasing breathlessness or work of breathing
  • A rising or unusually low respiratory rate
  • New noisy breathing, wheeze, stridor or difficulty speaking
  • Falling oxygen saturation where this is being monitored
  • New chest pain, dizziness or fainting
  • Pale, cool, clammy or mottled skin
  • A faster, slower or newly irregular pulse
  • Falling blood pressure alongside other signs of illness
  • New confusion, agitation, drowsiness or reduced responsiveness
  • Fever or an unusually low temperature
  • New weakness, reduced mobility or difficulty communicating
  • Persistent vomiting, poor oral intake or reduced urine output
  • A rapid change from the person’s usual condition

Not every patient will show the same pattern. The important skill is recognising when the overall clinical picture has changed and treating that change seriously.

Start with what is normal for the patient

Observations matter, but they need context. A result that looks acceptable on its own may still be concerning if it represents a marked change from that person’s usual state.

This is especially important when supporting older people, people with long-term conditions or patients whose normal observations differ from standard reference ranges. Someone with chronic respiratory disease, for example, may have a usual oxygen saturation that differs from another patient’s. A frail resident may first show illness by becoming quieter, less mobile or less interested in eating rather than by developing dramatic symptoms.

Ask what has changed. The patient may be able to tell you. A relative, carer or colleague who knows them well may also provide important information. Comments such as “she is much sleepier than normal” or “he is usually much more alert” should form part of the assessment rather than being dismissed because they are not a numerical observation.

This principle is particularly important in care environments, where staff often know residents well enough to notice subtle changes before they become obvious to someone seeing the person for the first time.

Look at the patient before the monitor

Monitoring equipment provides useful information, but the patient remains the most important source of information. Someone can look seriously unwell before every measurement has moved outside its expected range.

Observe how the person is breathing, speaking and interacting. Are they able to finish a sentence? Do they appear exhausted? Has their skin colour changed? Are they responding normally to questions? Do they appear frightened, restless or unusually withdrawn?

If a reading does not fit the clinical picture, repeat it and check the equipment where appropriate. Do not, however, allow repeated attempts to obtain a perfect set of observations to delay escalation when the patient is clearly becoming more unwell.

Recognise changes in breathing and airway

Breathing often provides some of the earliest clues that a patient is deteriorating. Look for changes in respiratory rate and effort rather than focusing only on whether the person says they feel short of breath.

A patient may begin using the muscles around the neck and shoulders to breathe, sit forward to make breathing easier, become unable to speak comfortably in full sentences or appear increasingly anxious. New wheeze, noisy breathing or stridor should be taken seriously. A change in voice, facial or tongue swelling and rapidly increasing breathing difficulty can indicate significant airway compromise and require urgent action.

Be equally cautious if a patient who has been working hard to breathe becomes quieter, more drowsy or starts breathing more slowly. That does not necessarily mean they are improving. It may indicate exhaustion and worsening respiratory failure.

Watch for changes in circulation

Circulatory deterioration can appear in several ways. A patient may become pale, cool, clammy or mottled. They may report dizziness, weakness or chest discomfort. Their pulse may become faster, slower or irregular, and blood pressure may begin to fall.

No single measurement should be interpreted in isolation. A raised heart rate may have several causes, including pain, fever, dehydration, anxiety or more serious illness. Equally, an apparently acceptable blood pressure does not automatically rule out deterioration if the patient looks unwell or other observations are changing.

The pattern matters. A rising pulse, worsening skin signs, increasing respiratory rate and falling blood pressure together carry a different significance from one mildly abnormal measurement recorded once.

Take new confusion or reduced responsiveness seriously

A change in consciousness or behaviour is an important sign of deterioration. New confusion, agitation, unusual sleepiness or reduced responsiveness can be associated with hypoxia, infection, metabolic disturbance, neurological problems and other serious conditions.

Older patients and people living with dementia may not present in a textbook way. An acute change in attention, behaviour or communication may be one of the first noticeable signs that something has changed clinically.

Assess and record the patient’s level of responsiveness using the approach used within your setting. What matters is that it is repeatable, clearly documented and compared with previous findings. A patient becoming progressively more difficult to rouse needs prompt escalation.

Use ABCDE to assess a deteriorating patient

Once deterioration is suspected, a structured assessment helps prevent important problems being missed. The ABCDE approach moves through Airway, Breathing, Circulation, Disability and Exposure, dealing with life-threatening problems as they are identified rather than waiting until the entire assessment has been completed.

Airway

Check whether the airway is open and whether there are signs of obstruction or a developing airway problem. Look and listen for abnormal sounds and consider whether swelling, secretions, vomiting or another problem may be compromising the airway.

Breathing

Assess respiratory rate and effort, chest movement and oxygen saturation where appropriate and available. Look at the patient as well as the numbers. Severe effort, exhaustion, cyanosis or rapidly changing observations should prompt urgent escalation.

Circulation

Assess pulse, blood pressure where available, skin appearance and other signs of perfusion appropriate to the setting. Consider any obvious bleeding and the wider pattern of observations rather than concentrating on a single result.

Disability

Consider level of consciousness, new confusion and any other neurological change. Blood glucose may also need checking where indicated and within the person’s role and local procedure.

Exposure

Look for other relevant signs such as rash, swelling, injury, bleeding, temperature change or evidence of infection, while maintaining dignity and preventing unnecessary heat loss.

The assessment does not end after reaching Exposure. Reassess the patient, particularly after an intervention or if their condition continues to change. Immediate Life Support training develops this structured approach further, helping healthcare professionals recognise and manage deterioration before a patient progresses to cardiac arrest.

Why trends are often more useful than one set of observations

A single set of observations captures one point in time. Repeated observations show direction.

A respiratory rate that has risen across several assessments, oxygen saturation that is gradually falling from the patient’s normal level or a pulse that continues to increase can reveal deterioration before one measurement appears dramatically abnormal.

This is why accurate timing and documentation matter. Record what was observed, when it changed, what action was taken and how the patient responded. A clear timeline helps colleagues and receiving clinicians understand whether the condition has changed gradually or rapidly.

Frequency of reassessment should reflect the patient’s condition and local escalation procedures. A patient who is becoming progressively more unwell should not simply be left until the next routine observation round.

Where NEWS2 fits into recognising deterioration

In services where the National Early Warning Score 2, or NEWS2, forms part of local practice, it can support the identification and escalation of acute illness in adults. The score brings together physiological observations to help highlight patients who may require closer monitoring or clinical review.

NEWS2 should support clinical judgement rather than replace it. A concerning change from baseline, rapid deterioration or a strong clinical concern may require escalation even where the total score does not appear particularly high.

The same principle works in the opposite direction. An abnormal score needs to be acted on according to the organisation’s agreed escalation pathway rather than recorded without a response.

Where NEWS2 is not used, staff should follow the assessment and escalation system appropriate to their clinical environment.

Know when deterioration needs urgent escalation

Recognising that a patient is deteriorating is only useful if the concern reaches the right person quickly.

Escalation depends on the severity of the patient’s condition, the clinical environment and the support available. It may involve a senior clinician, GP, urgent clinical service, local emergency or resuscitation team, or the ambulance service.

If there is an immediate threat to life, emergency assistance should be summoned without delay while appropriate care continues within the team’s training, competence and local procedure.

Do not wait for a complete diagnosis before escalating a seriously unwell patient. The purpose of early recognition is precisely to bring additional assessment and treatment into the situation before the patient deteriorates further.

Give a handover that shows what has changed

A good clinical handover should make the trajectory of deterioration clear, not simply provide a list of observations.

SBAR can provide a useful structure:

  • Situation – Who the patient is and what is happening now
  • Background – Relevant history, treatment, allergies and usual condition
  • Assessment – Current observations, ABCDE findings and how they have changed
  • Recommendation – The review, support or action you believe is needed

Be specific about concern. Saying, “I am concerned this patient is deteriorating because their respiratory rate is rising and they are becoming increasingly drowsy” gives the receiving clinician a clearer picture than simply saying the patient “doesn’t look well”.

Record who was contacted, when the escalation took place, what advice was received and what happened next.

Clinical concern still matters

Structured assessments, observations and early warning scores are valuable because they give healthcare teams a common framework. They should not remove professional judgement from the response.

If the patient looks significantly different from their usual state, their condition is changing quickly or the overall clinical picture is worrying, act on that concern. Waiting for every abnormality to align neatly can lose the advantage that early recognition is meant to provide.

Human factors can also influence what staff notice and how quickly they respond. Assumptions, distractions and fixation on an initial explanation can all make deterioration easier to miss. Recognising deterioration is a practical skill

The signs of patient deterioration can be learned from a chart, but recognising them in practice is more difficult. Real patients may have several conditions at once, observations may change gradually and the first warning may simply be that something does not fit the person’s normal presentation.

That is why practical emergency training matters. Realistic scenarios allow healthcare professionals to combine observation, ABCDE assessment, communication, escalation and reassessment rather than learning each skill separately.

At RCMS Life Support, clinician-led training is designed around that practical reality. The aim is not simply to recognise an abnormal number. It is to recognise the patient who is becoming unwell, understand what needs immediate attention and know when further clinical support is required.

Early recognition does not remove uncertainty from an emergency. It gives the team more time to act. Notice the change, assess the patient systematically, follow the trend and escalate concern before deterioration becomes collapse.

FAQs About Recognising Patient Deterioration

Does a DNACPR recommendation affect how a deteriorating patient should be treated?

A DNACPR recommendation relates specifically to whether cardiopulmonary resuscitation should be attempted if the person has a cardiac arrest. It does not mean that other appropriate treatment should be withheld. If a deteriorating patient has a DNACPR recommendation or a wider emergency care plan such as ReSPECT, staff should check the documented recommendations and continue to provide appropriate assessment, treatment and escalation in line with the person’s care plan and clinical needs.

Can patients or families ask for another clinical review if they believe deterioration is being missed?

Yes. Patients, relatives and carers can raise concerns when they believe a person’s condition is worsening or their concerns have not been acted upon. They should use the escalation process available within the service. In NHS hospitals in England where Martha’s Rule is available, patients, families and carers can also request a rapid review from a different clinical team if they are worried that deterioration is not being adequately addressed.

Can medication make patient deterioration more difficult to recognise?

Medication can affect how a patient presents and how some observations should be interpreted. Medicines may influence heart rate, blood pressure, breathing, consciousness or other clinical findings, while adverse drug reactions can themselves cause deterioration. A current medication history is therefore useful when assessing an unwell patient, particularly when there has been a recent prescription, dose change or newly administered medicine.

What should happen if a patient deteriorates during transfer between care settings?

A change in condition during transfer should be treated as a new clinical concern rather than simply left for the receiving team to assess. The appropriate response will depend on the severity of the deterioration, the staff and equipment available and the type of transfer taking place. Unexpected or significant deterioration may require the transfer plan to change, urgent clinical advice or emergency assistance. Any change in condition and action taken should also be communicated clearly to the receiving service.

Does recent sedation or a clinical procedure change how deterioration should be assessed?

Recent sedation, treatment or a clinical procedure can provide important context when a patient becomes unwell. Staff should consider complications relevant to the procedure or medicines used, while avoiding the assumption that every new symptom is an expected after-effect. Unexpected changes in breathing, consciousness, circulation, bleeding, pain or general condition should be assessed promptly and managed according to the setting’s post-procedure and emergency procedures.