Recognising a Deteriorating Patient: An Illustrated Nursing Guide to ABCDE and SBAR

Clinical nursing • Illustrated bedside guide

When a patient starts to deteriorate, the first clue may be a small change: faster breathing, unusual restlessness, or a relative saying, “This is not how he normally behaves.”

For a nurse, taking observations is only the beginning. The next questions are: what has changed, how urgent is it, and who needs to know? This guide uses an adult ward example to connect assessment with action.

1. Notice the change before it becomes a crisis

An observation chart should tell a story over time. Compare the current findings with earlier readings and the patient’s usual condition. Listen to what the patient and family are reporting. NICE recommends a response to deterioration based on the observation score or clinical concern; concern does not need to wait for a high score. [1]

Measure, compare, communicate

Record respiratory rate, oxygen saturation, pulse, blood pressure, temperature and level of consciousness using the local observation system. Document oxygen use, including its device and flow, where applicable. Increase monitoring and escalate when indicated by the findings and local policy. A number without a time, a trend or an action is an incomplete account of what happened. [1]

2. Use ABCDE to organise your assessment

ABCDE means Airway, Breathing, Circulation, Disability and Exposure. Assess systematically, address immediate threats as you find them, call for appropriate help early and reassess after interventions. It is a repeating assessment, not a form to finish before requesting assistance. [2]

A — Is the airway clear?

Check whether the patient can speak and whether there are signs of obstruction, such as noisy breathing or gurgling. An airway problem needs immediate skilled help and airway support within your training. Do not continue down a checklist while an obvious life threat remains untreated. [2]

B — How is the patient breathing?

Count respirations, observe effort and chest movement, and check oxygen saturation. Use chest examination skills within your competence. Record what you actually see rather than writing “breathing normal” without an assessment. [2]

C — Is circulation adequate?

Assess pulse, blood pressure, peripheral perfusion and possible bleeding. Review available fluid balance information. Report changes with their times and relevant symptoms. Decisions about fluids and other treatment need clinical assessment and the appropriate authorised plan. [4]

D — Has consciousness changed?

Assess responsiveness using the facility’s approved method, establish the baseline and check blood glucose when consciousness changes. Hypoglycaemia is a reversible cause that must be considered. Maintain close observation and escalate; follow the local treatment and repeat-check protocol if a low result is found. [4]

E — What else needs to be seen?

Inspect for relevant findings, including bleeding, wounds or a rash, while maintaining privacy and warmth. Measure temperature and complete the focused assessment. Expose only what is necessary. [2]

3. Work through a ward scenario

Fictional teaching case: Mr Musa, 58, is admitted with a chest infection. At 08:00 he is alert, speaking comfortably and breathing 18 times per minute. At 10:00 he says he feels worse. He can speak, but only in short phrases. His respiratory rate is 30/min, SpO₂ is 90% on room air, pulse 118/min and blood pressure 96/60 mmHg. He is newly confused.

Pause before reading further. What would you say to the nurse in charge? Which information matters most? Would you wait for the next routine observation round?

A useful teaching exercise is to give one student the assessment role, another the escalation call, and a third the documentation role. Ask the observer to note whether the team gave exact readings, stated that the confusion was new and requested an immediate review. Practise saying the words aloud: an urgent situation is a poor time to discover that your message is unclear.

4. Make the escalation call clear with SBAR

SBAR structures information into Situation, Background, Assessment and Recommendation or Request. State the urgent problem early, give relevant context, describe your findings and say what you need and when. Confirm the response and clarify any instructions. [6]

In a real call, use your organisation’s approved patient identifiers and report the care already provided and the response to it. If the first contact does not respond, continue along the escalation pathway. Record the call time, who was contacted, advice received and the subsequent review. [1]

5. Close the loop: reassess and document

After an intervention, ask: what changed? Repeat the relevant assessment and record the response. During handover or transfer, explain what remains unresolved, what treatment is ongoing and what monitoring is required. A handover is not complete simply because the patient has physically arrived elsewhere. [4] [6]

Documentation exercise: Rewrite “patient not well, doctor informed” using the fictional case. Include the time, the patient’s statement, objective observations, who you called, what you requested and what happened next. Leave no invented treatment or outcome in the note: if something has not happened, do not document it as completed.

6. Check your understanding

Try answering before opening each explanation.

A bedside habit to practise on your next shift

Choose one patient and explain their observation trend to your supervising nurse: what has changed, what it could mean, what needs checking and when you would escalate. Practise linking findings to a clear action. The aim is to make your assessment understandable to the next person caring for that patient.

Sources and further learning