Early Recognition of the
Deteriorating Patient
A guide for health
care providers
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Purpose
• To catch the patient and intervene when
compensatory mechanisms are kicking in, not
once they have already failed.
• Early recognition of subclinical signs with
resulting interventions produce better patient
outcomes
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What are Subclinical Signs
• Tell you that the patient is failing.
• Through compensatory mechanisms, he is still
able to maintain and keep his vital signs
“normal”.
• Goal – Recognize and intervene before the
crisis occurs.
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The Look Test
How does your patient look in regards to:
• Color
– Skin color is a factor of pigmentation and oxygenation and
perfusion in the capillaries. People are not supposed to
change color.
• Effort and Fatigability
– How hard is the patient working to maintain his vital signs?
– How long will he be able to keep going before his vital
signs start to deteriorate?
• Diaphoresis (Sweating)
– Sign of maximal sympathetic stimulation; the patient is
using the last of everything he has to maintain vital signs.
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The Look Test cont.
• Mentation
– One of the earliest signs of inadequate oxygenation is a change in
mentation.
• Signs of Inadequate Perfusion
– Relaxation of Ear and Nose Cartilage: With lack of oxygenation and
perfusion, the cartilage becomes soft, causing the ears to lay back against the
head. Nasal Cannula keeps falling off.
– Knee and Scrotum mottling
– Generalized Pallor
– GI Symptoms: Indigestion, heartburn, constipation, nausea and loss of
appetite can all be signs of heart failure due to vasoconstriction in the gut.
• Voice Quality
– Indicates oxygenation and perfusion
– Clarity of ideas and strength of the voice
– The number of words the patient can string together in a sentence before
gasping for breath is an indication of tidal volumes the patient is able to
generate
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Vital Signs
• Vital Signs
– One set of vitals standing alone is meaningless. Evaluate over the
course of time
– Know a patient’s trend and where that number falls along that
patient’s continuum.
• If the VS number does not make sense, repeat it. If it still does
not make sense, get a second nursing opinion.
• Does the HR on the pulse ox machine correlate with apical
HR?
• How was the measurement taken (manual or automatic)?
• If you cannot obtain a reading, why?
– Check the patient with a manual BP cuff, listen to apical HR, count the
respirations.
– ask for an order for an ABG if the patient’s SaO2 is not reading.
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First Two Signs of Compensation
•HR and RR start to climb
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Heart Rate
• An elevated HR is a sign of your patient using
a compensatory mechanism.
• Heart rate will go up when there is a greater
need for oxygen by the cell (i.e. response to
injury, exercise), or when there is not an
adequate supply of oxygen to bring to the cell
(hypovolemia, anemia, hypoxia).
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Respiratory Rate
• The symptoms of hypoxemia are
identical to the symptoms of anxiety,
including: restlessness, confusion,
agitation, combativeness
• Never medicate a patient for symptoms
of “anxiety” until you rule out hypoxemia
as a cause.
• Most common causes of increased
respiratory rate is hypoxemia or
compensation for metabolic acidosis.
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Blood Pressure
• Change in blood pressure can occur
rapidly or gradually based on the
presenting condition.
• Watch trends; know your patient’s
baseline.
• Whether your patient is hyper- or
hypotensive, it is all about tissue
perfusion. BP that is too high or too
low will not adequately oxygenate the
tissues.
• Is the patient symptomatic?
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Urine Output
• Urine output starts to drop off long before it
becomes too low or abnormal.
• LOOK AT THE TRENDS FOR URINE OUTPUT.
When it starts declining, you may have a
perfusion problem.
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Rapid Response Team
• Purpose – To provide urgent medical
assistance and interventions for patients who
experience an acute medical event to
promote better patient outcomes.
• RRT Members: ICU Nurse, Respiratory
Therapist, Nurse assigned to patient
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When to Call RRT
• “Being worried about a patient”
• “Having a gut feeling”
• Acute changes:
HR <40 or >130
BP<90 and symptomatic
Respiratory rate <6 or >30
Changes in Neuro status
Saturation <90% despite oxygen
New onset or repeated seizure activity
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Calling a RRT
• Any Patient Care Provider can call
an RRT
• DIAL 71
• Ask operator to call Rapid
Response and give the patient’s
room and bed number
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