The deteriorating patient at the end of a busy shift
It is 19:20 on a 12-hour day shift on a 30-bed medical ward. You are the registered nurse for 9 patients; the ward has one healthcare support worker per 8 patients and no supernumerary shift coordinator because the coordinator is covering a sick call on another ward. Mrs Iqbal, 78, admitted 3 days ago with pneumonia, has a NEWS2 of 6 (respiratory rate 26, SpO2 91% on 2 L, systolic BP 96, pulse 108, temperature 38.4°C, new confusion). Her ceiling of treatment is 'for full active treatment'. The ward doctor is in theatre and the on-call medical registrar is covering three wards. Your 20:00 medication round is due and two patients need IV antibiotics within the next 30 minutes. A family member is at the desk asking why his mother's analgesia was late.
1. What are your immediate clinical priorities in the next 15 minutes, and how do you sequence them?
Read the worked answer
Recognise and escalate first, then stabilise, then delegate.
- Stay with Mrs Iqbal and call for help. A NEWS2 of 6 with new confusion and hypotension meets the threshold for an urgent/emergency response. Do not leave to complete the drug round first.
- Apply the ABCDE approach. Airway patent but confused; assess breathing (increase oxygen to target 94–98% for most medical patients, reassess SpO2), circulation (repeat BP, capillary refill, urine output), disability (new confusion - check glucose, temperature, consider sepsis screen), exposure (look for source, check for rash, wounds, catheter).
- Escalate in parallel. Ask the HCSW to call the medical registrar now with a structured SBAR (Situation, Background, Assessment, Recommendation) and to state NEWS2 = 6 with new confusion. If no timely response, escalate to the nurse in charge and, per local policy, to the critical care outreach team or on-call consultant.
- Start the sepsis pathway if criteria are met. New confusion + RR ≥22 + SBP ≤100 gives a qSOFA of 3; combined with suspected infection this warrants urgent senior review, blood cultures, lactate, and IV antibiotics within 1 hour per NICE sepsis guidance. Take cultures before antibiotics if this does not delay them.
- Delegate and document. The HCSW can obtain vital signs, fluid balance and glucose while you stay with the patient. Ask the nurse in charge to oversee the antibiotic round for the other two patients and to acknowledge the family member with a clear time frame. Document contemporaneously.
Key judgement: deteriorating patient > routine task completion; escalate early and in parallel, not sequentially.
2. The registrar says she cannot attend for at least 45 minutes. What do you do, and what professional standards guide you?
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Escalate beyond the first responder; do not accept an unsafe delay passively.
- Re-state the concern using objective data. Call back and give a clear SBAR with numbers: NEWS2 6, new confusion, SBP 96, SpO2 91% on 2 L. Ask explicitly: 'Are you able to attend within 15 minutes, or should I escalate to the consultant/outreach now?'
- Use the chain of escalation. Per local policy, escalate to the nurse in charge, critical care outreach, and the on-call consultant. If the patient is peri-arrest, call 2222/999 per policy.
- Initiate agreed emergency treatment within your competence. Oxygen titration, IV access, fluids if prescribed or via a patient group direction, blood cultures, lactate, glucose, and continuous monitoring. Do not administer unprescribed medicines outside a PGD.
- Record the escalation and the response times. This is both good practice and evidence if the case is reviewed.
Professional standards (NMC Code):
- Prioritise people - act in the patient's best interests, treat with dignity, recognise deterioration.
- Practise effectively - work within competence, use evidence-based tools (NEWS2, sepsis pathway), keep skills current.
- Preserve safety - raise concerns immediately when patient safety is at risk, use the escalation policy, and do not let hierarchy delay care.
- Promote professionalism and trust - be accountable for your decisions and document them.
Judgement: the registrar's delay does not transfer accountability to you alone; you must escalate, act within competence, and document.
3. The family member becomes angry that his mother's analgesia is late. How do you respond while maintaining safety of the deteriorating patient?
Read the worked answer
Acknowledge, be honest, set a realistic time frame, and return to the clinical priority.
- Brief acknowledgement at the bedside/desk (30–60 seconds). 'I'm sorry your mother's pain relief is late. I'm with a patient who has become very unwell; I will make sure your mother is seen within the next 15 minutes. I'll come back to you as soon as I can.' Use the person's name, make eye contact, avoid defensiveness.
- Delegate the task safely. Ask the nurse in charge or a colleague to review the analgesia now; if the prescription is due and within your competence, hand over clearly with the prescription chart and timing.
- Do not abandon the deteriorating patient to manage the complaint. Safety of the acutely unwell patient takes precedence; communication can be brief and honest.
- De-escalate if anger escalates. Use calm tone, open posture, offer a private space, involve the nurse in charge if needed. Follow the trust's violence and aggression policy if there is any threat.
- Follow up and document. Return to the family member when able, explain what happened, apologise for the delay (an apology is not an admission of liability), and record the conversation and actions.
Standards: NMC Code - treat people with kindness, respect and dignity; listen and respond to concerns; be open and honest; work co-operatively with colleagues. Communication must be person-centred but must not compromise clinical safety.