Signs a Patient Is Getting Worse: A Guide for Any Role

You do not need clinical training to notice the signs a patient is getting worse. Most of the signs are visible from the end of the bed: a change in colour, a change in breathing, a change in how the person behaves. The job of a cleaner, a porter, a receptionist or a nursing assistant is not to decide what is wrong. It is to notice the change and tell a nurse now, in person, with the words "I think this patient is getting worse." This article shows you what to look for, why "they seemed fine an hour ago" matters, and how to raise it.

Colour, breathing, behaviour

Three things to look at, in any order. Any one of them changing is enough to speak.

Colour

Skin that has gone pale, grey or has a blue tinge around the lips, fingertips or ear lobes.
Skin that looks blotchy or mottled, like marble, especially on the knees, arms or chest.
A sudden flush or sweating when the room is not hot. Clammy skin, cold to the touch.
On darker skin, look at the lips, the inside of the mouth, the nail beds and the palms, where colour changes show first.

Breathing

Breathing that is faster than when you last saw them, or that looks like hard work: shoulders lifting, nostrils flaring, stopping mid-sentence for air.
Noisy breathing: wheeze, rattle, gurgle, or a grunt at the end of each breath.
Breathing that is very slow, or that pauses.
Using the arms to prop themselves up to breathe, or refusing to lie back.

Behaviour

New confusion. The patient who knew where they were this morning now asks for their mother.
Unusual sleepiness: hard to wake, drifts off mid-sentence, does not respond to their name.
Agitation, pulling at lines, trying to climb out of bed when they were calm before.
A patient who says "I feel awful," "something is wrong," or "I think I'm dying." Take those words seriously every time.
Quiet. A patient who was chatty and is now silent and staring.

Add two more that do not fit the three: not passing urine for a long time when they usually do, and new pain that makes them hold still or cry out.

The sepsis warning signs that any hospital worker can spot go deeper on the combination of these signs that should make you move fastest.

They seemed fine an hour ago

The most important word in this article is change. A patient who has always looked grey and breathless may be at their normal. A patient who was pink and joking at breakfast and is grey and quiet at eleven has changed, and change in a short time is a warning sign on its own.

This is why non-clinical staff matter. You see the same patients at the same times each day. The cleaner sees bay 3 every morning. The porter took Mr Hassan to X-ray on Monday and brings him back on Wednesday. You are often the person who last saw the patient at their normal and sees them now at something else.

So the sentence to use is not "he looks bad." It is: "He looked fine at nine when I did his bed space. He's grey and he's breathing fast now." Before and after, in one line. That is what the nurse needs.

Listen to the family

Relatives know the patient's normal better than anyone on the ward. When a daughter says "Mum isn't right," she is usually correct, even if she cannot say why. When the patient says it about themselves, they are usually correct too.

If a relative stops you in the corridor with a worry, do not say "I'm only the porter." Say: "I'll get a nurse to come and look now," and do it. Then tell the nurse exactly what the relative said, in their words. Some hospitals have a formal way for families to request a review when they are worried; your ward's procedure will say whether yours does and how it works.

Who to tell, how fast

The rule for every role is the same: tell the nurse responsible for that patient, in person, now. Not at the end of your round, not after you finish the next bay, not on a note.

How fast depends on what you saw:

Patient not responding, not breathing normally, or collapsed: use your hospital's emergency call procedure immediately. Shout for help, press the emergency buzzer by the bed, and follow the number and words your employer trained you to use. Stay with the patient. What to do during a crash call as support staff covers what happens next.
Blue lips, breathing that looks like hard work, new confusion, grey or mottled skin, a patient saying something is badly wrong: find a nurse now. If you cannot see one, use the nurse call or the emergency buzzer. Being wrong about the buzzer costs a minute; being wrong about waiting can cost a life.
A change that worries you but the patient is talking and breathing comfortably: tell the nurse before you leave the bay. Use the before-and-after sentence.

When you tell the nurse, say what you saw, not what you think the diagnosis is. "Bed 6, Mrs Carter, she was chatting at ten, she's now very sleepy and her lips look blue." The nurse takes it from there. If you are a nursing assistant who takes observations, the steps to take when an early warning score is rising tell you what the numbers add to what you saw.

Then stay if the nurse asks you to. A frightened patient wants a face they know, and the nurse may need the observation machine fetched.

An example from a domestic in a side room

Say you are a domestic on a medical ward. At eight you cleaned the side room where Mr Lindqvist is. He was sitting up with the television on, and he asked you to move the table so he could reach his tea. At half past eleven you go back because the bin needs changing.

He is lying flat, which he was not before. The television is still on, but he is not watching it. His face is pale, with a grey look around the mouth. He is breathing fast, and each breath has a small grunt at the end. His tea has not been touched. When you say "Morning again, Mr Lindqvist," he turns his head slowly and says "I don't feel right," then closes his eyes.

You do not change the bin. You step into the corridor and see the nurse at the drug trolley. You say: "Sorry to interrupt, I think Mr Lindqvist in side room two is getting worse. He was fine at eight, sitting up and chatting. He's now flat, grey, breathing fast with a grunt, and he says he doesn't feel right." The nurse locks the trolley and goes. You stay by the door in case she needs the observation machine fetched.

What you did was look, compare with earlier, and say it in one line. That is the whole skill.

When this does not work

The nurse says "He's always like that." Say what you compared it with: "He wasn't like that at eight." If you are still worried, say so plainly: "I'd feel better if someone looked at him." A nurse hearing that will almost always go. If nobody goes and you remain worried, tell the nurse in charge. How to speak up to a senior colleague about safety gives the words for the second and third time of asking.

You cannot find a nurse. Use the call bell at the bed or the emergency buzzer. Ask the ward clerk to find the nurse in charge. Do not leave the patient to go and search.

You were wrong. The nurse checks and the patient is fine. Nobody minds. Every nurse would rather be called ten times for nothing than miss the one that mattered.

The patient asks you not to say anything. Tell them you have to, kindly: "I'm not allowed to keep that to myself, and I'd rather someone checked." Then tell the nurse.

The overview of what every role does in a hospital emergency connects it to escalation calls, crash calls and fire.

Learn this in five minutes

The track Recognising a Patient Who Is Getting Worse teaches the look of deterioration in colour, breathing and behaviour, why a sudden change matters more than a steady state, how to listen to patients and families who say something is wrong, who to tell and how fast in each role, and what to do while help arrives. Five lessons for every job on the ward.