Recognizing a Deteriorating Patient
Spot the early signs that a patient is declining, and escalate in time for it to matter.
By the end of this lesson you can
- Recognize early signs of clinical deterioration
- Escalate concerns effectively, including when dismissed
- Respond to a fall, a seizure, and choking within your scope
- Describe your role during a code
Lesson Notes
Read through the key concepts before you try the challenge.
Escalating when the first report does not land
A patient who is 'just not right'
A patient who has been chatty all week is quiet and says she feels strange. Her vital signs are within normal limits. You report it and the nurse says they will look later. You are still worried.
- 1
Take a full set of vitals and compare each to her baseline.
'Within normal limits' is not the same as 'unchanged'. A pulse of 96 in someone who has run 62 all week is a 34-beat rise, and the normal range conceals it completely. Bring the comparison, not just the numbers.
- 2
Report again, and say plainly that you are concerned.
The nurse prioritized without seeing what you saw. Your continued concern is new information, and saying 'I'm worried about her' is a recognized escalation signal in most facilities — it is not being difficult.
- 3
Name the change rather than the impression.
'She's not herself' is easy to deprioritize. 'She's been talkative all week, she's barely spoken this afternoon, her pulse is up 34 from baseline, and she says she feels strange' is not.
- 4
If it is still not acted on, go to the charge nurse.
Going up the chain is what the chain is for. It is not going over anyone's head — it is the escalation path existing for exactly this situation, and nobody is disciplined for using it.
- 5
Consider the rapid response team if your facility lets any staff member activate it.
Many do, precisely because the person at the bedside notices first. Activating one and being wrong costs a team a few minutes; not activating and being right costs far more.
- 6
Document what you observed, when you reported it, and to whom.
It is a clinical record of a real change, and it is also a contemporaneous account of what you did. Both matter.
Result: The patient is seen, with a documented trail of what was noticed and when.
New confusion and 'I feel strange' are early signs, not vague ones. Bring the baseline comparison, say you are concerned, and go up the chain if it does not land.
You will notice it first
You are working a medical unit at Lakeside Regional.
A patient who has been chatty all week is quiet this afternoon and says she just feels 'strange.' Her vital signs are within normal limits. Nothing is objectively wrong, and you are the only person who knows how she has been for the last four days.
Your task: Learn to take early, non-specific change seriously and escalate it credibly.
Serious deterioration is usually preceded by hours of subtle change. Because PCTs spend the most time with patients, they frequently detect it before it appears in the numbers — and a change in mental status or a patient's own sense that something is wrong are among the most reliable early signals.
| Sign | Significance |
|---|---|
| New confusion or reduced alertness | Often the earliest sign of sepsis, hypoxia, or metabolic change |
| Rising respiratory rate | One of the earliest and most reliable indicators of deterioration |
| A patient saying they feel something is wrong | Take seriously — patients often sense decline before it is measurable |
| Falling oxygen saturation | Report promptly, particularly with rising respirations |
| Rising heart rate | Compensation for a developing problem |
| Falling blood pressure | Often a late sign — do not wait for it |
| Reduced urine output | Poor perfusion or dehydration |
| Cool, clammy, mottled skin | Poor perfusion |
| Event | Do | Do not |
|---|---|---|
| Fall | Stay with them, call for help, keep them still until assessed | Do not lift them up before a nurse assesses them |
| Seizure | Protect the head, clear the area, time it, turn them on their side afterwards | Do not restrain them or put anything in their mouth |
| Choking, able to cough | Encourage coughing; stay with them | Do not slap the back or intervene while coughing is effective |
| Choking, cannot speak or cough | Call for help and begin abdominal thrusts if trained | Do not leave them |
| Unresponsive | Call a code, check breathing and pulse, begin CPR if trained | Do not leave to find someone |
You report a concern about a patient's new confusion. The nurse is busy and says they will look later. The patient still worries you. What should you do?
Challenge
Apply what you've learned in this lesson.
Emergency response requires certification and practice; recognition can be studied now.
- Research sepsis. List the early signs a PCT could observe and explain why recognition speed matters so much.
- Research your local facility type's rapid response criteria. Note whether any staff member can activate it.
- Write an SBAR escalation for the patient in the opening scenario, in under fifty words.
- Find BLS certification requirements in your area — provider, cost, and renewal interval.
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