Clinical deterioration - identify and respond

The nurse must be able to identify and respond to deterioration in the clinical condition of patients. The Nursing and Midwifery Council (2018) requires nurses to be able to 'take, record and interpret vital signs manually and via technological devices', as well as to be able to 'identify and respond to signs of deterioration'. While some of this recognition arises from observation and nursing experience, this is not enough to protect the wellbeing of patients. Therefore, tools exist to support the nurse to be more objective when making observations for clinical deterioration. The best-known tool in the UK is the National Early Warning Score 2 (NEWS2) (Royal College of Physicians, 2017).

NEWS2 works on the premise that the vital signs of an individual can be scored, and changes in this score over time are indicative of a change in a patient's clinical condition. This article identifies how NEWS2 is applied

While the aim of NEWS2 is to provide an objective means of assessing the health status of patients, nurses must also take into account the person's presentations and what they communicate, as well as the nurse's own observations. Combining the objective measures with the subjective measures (eg symptoms) and other signs enables the nurse to validate the measurements they obtain (Ellis and Standing, 2023).

The Royal College of Physicians (2017) recommend the use of NEWS2 across the NHS as a means of gaining a standardised measure of the physiological parameters of individual patients, especially:

• in clinical assessments of the severity of acute illness
• when detecting clinical deterioration through monitoring trends
• for prompting a timely clinical response

NEWS2 is not suitable for use in:

• people under the age of 16 years
• pregnant women

NEWS2 may be unreliable when used with people who:

• have spinal cord injuries

The equipment required to undertake monitoring will depend on the situation in which the nurse is working and the equipment that is available to them. To undertake basic vital sign monitoring, the nurse will need:

• a sphygmomanometer
  • if not electric, a stethoscope with a diaphragm face
  • with a correct sized cuff (Irving et al, 2016)
• a thermometer
  • with thermometer sheathing (eg for tympanic or electric oral thermometers), where needed
• a watch or other means of measuring time
• a pulse oximeter
• cleaning materials to disinfect equipment between uses
• the patient's record

The nurse should ensure they gain consent before monitoring vital signs by explaining the nature of the procedure and why it is being undertaken to the patient. Nurses should undertake hand hygiene prior to taking a blood pressure to minimise the risk of transmitting infection.

Dobson and Simpson (2022) suggested that the patient should be rested, if possible, prior to taking vital sign recordings in order to ensure the results are as accurate as possible. The nurse should address any privacy and dignity issues associated with the procedure.

The sum of six physiological parameters are added to produce NEWS2:

1. respiration rate
2. oxygen saturation
3. systolic blood pressure
4. pulse rate
5. level of consciousness or new confusion (where previously normal)
6. temperature

A score of 0-3 is given to each parameter, with a higher score indicating a greater deviance from the 'normal' range. These scores are then added together, with an additional two points

One of the main risks faced by patients whose condition is deteriorating is the potential for this not to be identified or acted upon. Some nurses may not understand, fail to correctly interpret or to act appropriately on the NEWS2 score, which may put the health and wellbeing of patients at risk.

Overreliance on NEWS2 without considering the broader clinical picture my result in misinterpretation of the patient's state. Some components, such as respiratory rate and oxygen saturation, can be subjective and influenced by certain factors, such as patient anxiety or improper measurement technique. NEWS2 may not always detect specific clinical conditions, such as early sepsis or neurological deterioration, which may not manifest as changes in the six vital signs. NEWS2 may not be sensitive enough to detect subtle changes in certain patient populations, such as those with chronic conditions, potentially leading to missed deterioration.

Effective communication and response to

Being able not only to identify deterioration in patients, but to also communicate this in a meaningful and standardised way to other healthcare professionals is a fundamental skill which all nurses should have (Nursing and Midwifery Council, 2018). Nurses working in settings where the monitoring, recognition and management of deterioration are important should ensure they are familiar with the requirements of NEWS2, including patient monitoring, scoring, interpretation of scores and responding appropriately.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1.2 physical health and wellbeing

1.2.3 symptoms and signs of deterioration and sepsis

2.1 take, record and interpret vital signs manually and via technological devices

Brangan E, Banks J, Brant H et al. Using the National Early Warning Score (NEWS) outside acute hospital settings: a qualitative study of staff experiences in the west of England. BMJ Open. 2018;8:e022528. https://doi.org/10.1136/bmjopen-2018-022528

Cardona-Morrell M, Prgomet M, Lake R et al. Vital signs monitoring and nurse–patient interaction: a qualitative observational study of hospital practice. Int J Nurs St. 2016;56:9-16. https://doi.org/10.1016/j.ijnurstu.2015.12.007

Carvalho F, Breen E-C, Bullock Z et al. Observations. In: Lister S, Hofland J, Grafton H and Wilson C (eds). The Royal Marsden manual of clinical nursing procedures. 10^th edn. Chichester: Wiley Blackwell; 2021

Dobson C, Simpson T. Clinical measurement. In: Delves-Yates C (ed). Essentials of nursing practice. 3rd edn. London: Sage; 2022

Ellis P, Standing M. Patient assessment and care planning in nursing. 4th edn. London: Sage; 2023

Irving G, Holden J, Stevens R et al. Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review. BMJ Open. 2016;6:e012429.