How to assess deteriorating patients nursing standard? A comprehensive guide for nurses

In clinical settings, early recognition and response to patient deterioration can prevent up to 70% of unexpected cardiac arrests. This definitive guide on how to assess deteriorating patients nursing standard empowers clinicians with the systematic tools and knowledge to proactively identify, manage, and escalate patient risks effectively.

Quick Summary

Assessing a deteriorating patient involves a structured, standardized approach like the ABCDE method, supported by objective vital sign monitoring via a scoring tool such as NEWS and clear, timely communication to the wider clinical team.

Key Points

• Systematic ABCDE Approach: Use the Airway, Breathing, Circulation, Disability, and Exposure method to rapidly assess and prioritize interventions for unwell patients.

• Objective Vital Sign Monitoring: Implement the National Early Warning Score (NEWS) to objectively track physiological changes and identify signs of deterioration early.

• Structured Communication: Employ the SBAR (Situation, Background, Assessment, Recommendation) tool for clear, concise, and timely clinical handover and escalation of concerns.

• Timely Escalation: Adhere strictly to institutional escalation policies and call for senior assistance, such as a Rapid Response or MET team, based on clinical triggers.

• Ongoing Reassessment: After every intervention, reassess the patient's condition and vital signs to evaluate the effectiveness of the treatment and identify any further changes.

• Meticulous Documentation: Maintain accurate and detailed records of all observations, assessments, and interventions to ensure continuity of care and a comprehensive clinical picture.

• Proactive Vigilance: Recognize that nursing vigilance and prompt action are crucial for intercepting patient decline before it progresses to a critical stage.

The Foundational Nursing Standard for Patient Assessment

The ABCDE Approach: A Systematic Framework

The Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) approach is the universally recognized nursing standard for assessing any acutely unwell or deteriorating patient. This structured method ensures that life-threatening problems are identified and managed in order of priority. Nurses must be proficient in its application, moving through each step methodically and treating immediate threats to life as they are discovered, before moving on to the next letter of the acronym.

A - Airway: The first and most critical step is ensuring a patent airway. Nurses assess for obstruction, check for signs like stridor or gurgling, and intervene with appropriate measures such as positioning, suctioning, or escalating to senior staff for more advanced airway support.

B - Breathing: Following a clear airway, the nurse assesses the patient's breathing, looking for rate, depth, and effort. Assessment includes observing chest wall movement, auscultating breath sounds, measuring oxygen saturation, and administering oxygen as required while investigating the underlying cause.

C - Circulation: Assessing circulation involves evaluating the patient's heart rate, blood pressure, peripheral perfusion (e.g., capillary refill time), and observing for signs of shock or hemorrhage. Actions include establishing intravenous access, taking bloods, and administering fluids or medication according to protocol.

D - Disability: A quick neurological assessment is performed to check the patient's level of consciousness, pupil response, and blood glucose level. The ACVPU or Glasgow Coma Scale (GCS) is used to score consciousness, while a finger-prick test quickly checks for hypoglycaemia.

E - Exposure: This final stage involves a thorough head-to-toe examination, protecting the patient's dignity, and preventing heat loss. The nurse looks for any signs of injury, rash, or other issues while maintaining appropriate temperature control.

Tools for Objective Assessment: The National Early Warning Score (NEWS)

The National Early Warning Score (NEWS) provides a standardized, objective method for monitoring and escalating the care of acutely ill patients. It assigns a numerical score to a set of physiological measurements, including:

• Respiratory Rate
• Oxygen Saturation
• Systolic Blood Pressure
• Pulse Rate
• Level of Consciousness (ACVPU)
• Temperature

This simple, points-based system allows nurses to track a patient's condition over time and trigger an appropriate and timely clinical response based on the aggregated score. An increasing NEWS score is a clear indicator of deterioration and a prompt to escalate care.

Comparison of Assessment Tools

Feature	ABCDE Approach	National Early Warning Score (NEWS)
Purpose	To provide a rapid, systematic assessment and intervention framework in an emergency.	To provide an objective, standardized metric for continuous monitoring and trigger escalation.
Application	Performed at the bedside during an acute event or initial assessment.	Used for routine monitoring at regular intervals (e.g., every 4, 6, 8 hours).
Trigger	Clinical judgement and immediate observation of patient distress.	A cumulative score based on physiological measurements.
Output	Prioritized actions based on the life-threatening problem identified.	A numerical score indicating severity of illness, with action guidance.

The Critical Role of Communication and Escalation

Even the most thorough assessment is incomplete without effective communication and timely escalation. Nurses play a crucial role in synthesizing their findings and communicating concerns to the wider multidisciplinary team.

The SBAR Communication Tool

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication technique used by nurses to provide concise and relevant updates to doctors or senior clinicians. It ensures all necessary information is conveyed efficiently, reducing the risk of miscommunication.

• S - Situation: Clearly state the patient's name, location, and the current problem.
• B - Background: Provide relevant patient history, including diagnosis, current treatment, and recent vital signs.
• A - Assessment: Give your clinical assessment based on the ABCDE approach and the NEWS score.
• R - Recommendation: Suggest what you believe needs to happen next, such as reviewing the patient, initiating new orders, or requesting a transfer.

The Escalation Pathway

Every healthcare facility has an escalation policy that outlines the steps to take when a patient's condition is worsening. This typically involves:

1. Initial recognition of a concerning sign or symptom.
2. Increased monitoring frequency based on NEWS score.
3. Calling for assistance from a rapid response team or medical emergency team (MET) when specific triggers are met.
4. Prompt clinical review by a doctor or senior nurse to determine further management.

Nursing Interventions for Deteriorating Patients

Once deterioration is identified, nursing interventions focus on stabilizing the patient and addressing the underlying cause. Common interventions include:

• Oxygen Therapy: Titrating oxygen to maintain target saturation levels.
• Fluid Resuscitation: Administering intravenous fluids for hypotension or dehydration.
• Positioning: Ensuring optimal positioning for breathing and comfort.
• Medication Administration: Promptly giving prescribed medications, such as pain relief or antiemetics.
• Monitoring and Reassessment: Continually re-evaluating the patient's ABCDE status and vital signs to assess the effectiveness of interventions.

Regular updates are essential. Nursing documentation should be meticulous, charting all observations, interventions, and communications clearly and concisely. For further reading, consult authoritative resources on patient safety.

Conclusion: The Professional Responsibility of Nurses

Mastering the nursing standard for assessing deteriorating patients is a non-negotiable professional responsibility. By adhering to a systematic approach like ABCDE, utilizing objective tools such as NEWS, and communicating effectively via frameworks like SBAR, nurses act as the frontline defense in patient safety. Their vigilance and timely, competent action can be the decisive factor in reversing a patient's decline and ensuring a positive outcome.

Key takeaway: The integration of methodical assessment, objective scoring, and clear communication is the core of the nursing standard for managing patient deterioration.

Frequently Asked Questions

What is the primary nursing standard for assessing patient deterioration?

The primary nursing standard is the systematic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, which prioritizes interventions based on the immediate threat to the patient's life.

How often should a nurse assess a deteriorating patient?

The frequency of assessment depends on the severity of the patient's condition, guided by the National Early Warning Score (NEWS). A higher NEWS score requires more frequent monitoring, potentially escalating to continuous observation.

What does a high NEWS score indicate?

A high NEWS score indicates significant physiological abnormalities and suggests the patient is at a higher risk of deteriorating further. It serves as a clear trigger for escalating the patient's care and summoning senior help.

When should a nurse escalate care for a deteriorating patient?

Care should be escalated immediately if the patient has a critical NEWS score, shows signs of life-threatening problems during an ABCDE assessment, or if the nurse's clinical judgment determines the patient is at risk.

What is the SBAR tool used for in the context of patient deterioration?

SBAR is a communication tool used to provide a structured update to other clinicians. It ensures that the Situation, Background, Assessment, and Recommendation are clearly and effectively communicated to facilitate timely decision-making.

What is the first step in assessing a deteriorating patient?

The very first step is to assess the patient's airway (A). A blocked airway can be fatal within minutes, so it must be secured before any other assessment steps are taken.

Can nurses manage a deteriorating patient on their own?

While nurses provide immediate stabilizing interventions, the standard of care requires timely escalation and collaboration with the wider healthcare team, including doctors and senior staff, to address the underlying cause of deterioration.

How does technology aid in assessing deteriorating patients?

Technology like electronic health records and bedside monitoring systems can help with continuous vital sign data collection and can automatically calculate NEWS scores, providing timely alerts for nurses to a patient's worsening condition.