The deteriorating patient and NEWS2
The staff nurse says the NEWS2 is high or the patient "doesn't look right". Go now, assess A–E, treat as you go, and get help early.
You are bleeped about a 58-year-old man two days after a bowel resection. His NEWS2 score has gone from 2 to 7 over 4 hours: RR 24, sats 94% on air, BP 102/68, pulse 112, temperature 38.3 °C, newly confused. The nurse says he "doesn't look right".
How urgently do you go, what do you look for, and when do you call for help?
- NEWS2 7 or moreEmergency response: see now, call senior and critical care outreach.
- NEWS2 5–6, or 3 in any one parameterUrgent review within 30 minutes.
- A to E assessmentTreat as you find.
- Bloods and gasLactate, FBC, U&E, CRP, cultures, glucose.
- Think sepsis firstAntibiotics within 1 hour if likely.
- Think of the surgeryAnastomotic leak, bleeding, PE, pneumonia, wound infection.
- Plan and documentEscalation level, observation frequency, when to review, resuscitation status.
- NEWS2 7 or more
- New confusion
- RR 25 or more or sats 91% or less (or below 88% on scale 2)
- Systolic below 90
- Lactate above 4
- Not improving 1 hour after treatment
- Sepsis
- Anastomotic leak
- Hidden bleeding
- PE
- Opioid toxicity
- Hypoglycaemia
- Acute kidney injury
- Silent MI
| NEWS2 0–4 | Ward-based response, observations every 4–6 hours (12-hourly if 0) |
| NEWS2 5–6 | Urgent review within 30 minutes, observations at least hourly |
| NEWS2 7 or more | Emergency team response, continuous monitoring |
| Single parameter scoring 3 | Urgent review by a doctor |
| New confusion | Scores 3 on its own |
| RR 25 or more | Scores 3 and is the most sensitive early sign |
| Lactate above 2 | Raised, above 4 is severe |
Check every dose against a current drug reference and your hospital protocol.
On this page
NEWS2 in short
NEWS2 scores six physiological measures plus oxygen use: RR, sats, oxygen given, systolic BP, pulse, consciousness (new confusion counts) and temperature. Each scores 0 to 3. Higher scores mean higher risk of deterioration.
| Parameter | Score 3 | Score 0 |
|---|---|---|
| RR | 8 or less, or 25 or more | 12–20 |
| Sats (scale 1) | 91% or less | 96% or more |
| Systolic BP | 90 or less, or 220 or more | 111–219 |
| Pulse | 40 or less, or 131 or more | 51–90 |
| Consciousness | New confusion, V, P or U | Alert |
| Temperature | 35.0 °C or less | 36.1–38.0 °C |
Scale 2 for sats is used in patients with confirmed CO₂ retention (target 88–92%).
The response
- Nurse-led, regular observations
- ask a doctor if worried
- Doctor within 30 minutes
- at least hourly observations
- Emergency assessment by a team with critical care skills
- continuous monitoring
A nurse saying "I'm worried" is a valid reason to review, whatever the score.
A to E at the bedside
- ATalking? Stridor? Secretions?
- BRR, sats, chest movement, breath sounds. Oxygen to target.
- CPulse, BP, capillary refill, JVP, heart sounds, urine output, drains, wounds. Two cannulas, bloods, fluid challenge if shocked.
- DGCS, pupils, glucose, drug chart (opioids, sedatives).
- ETemperature, abdomen, wounds, calves, lines, catheter.
- ReassessAfter each intervention. Call for help early.
Common causes on the ward
| Cause | Clues |
|---|---|
| Sepsis | Fever, high RR, source (chest, urine, wound, line) |
| Anastomotic leak | Day 3–7 after bowel surgery, abdominal pain, fever, tachycardia, ileus |
| Bleeding | Falling BP, rising pulse, drains, falling Hb |
| PE | Sudden breathlessness, tachycardia, hypoxia |
| Pneumonia or aspiration | Crackles, cough, hypoxia |
| Opioid toxicity | Pinpoint pupils, low RR, drowsy |
| Hypoglycaemia | Drowsy, sweaty; check glucose |
| AKI | Low urine output, rising creatinine, high potassium |
| MI or arrhythmia | Chest pain, ECG changes, new AF |
| Alcohol withdrawal | Day 2–3, tremor, agitation, sweating |
Investigations
| Test | Why |
|---|---|
| Blood gas with lactate | Perfusion, acid–base, potassium, glucose |
| FBC, U&E, CRP, LFT, clotting | Infection, bleeding, kidney injury |
| Blood cultures | Before antibiotics |
| ECG | MI, arrhythmia |
| Chest X-ray | Pneumonia, effusion, pneumothorax |
| CT abdomen | Suspected leak or collection |
| CTPA | Suspected PE |
Treatment
See sepsis, low blood pressure and low oxygen sats.
Escalation and communication
Use SBAR when calling your senior:
- Situation: "I'm calling about Mr X, NEWS2 7, I'm worried he's septic."
- Background: age, operation, day, key history.
- Assessment: findings, what you've done.
- Recommendation: what you need (review now, critical care, CT).
Document the plan, ceiling of care and resuscitation status. Agree when observations will be repeated and what should trigger another call.
Common mistakes
- Relying on the total score and ignoring a single red parameter.
- Missing a high RR (often not counted properly).
- Blaming confusion on "sundowning".
- Delaying antibiotics for imaging.
- Not calling a senior early.
- No plan written for the night nurse.
Frequently asked questions
What NEWS2 score needs an emergency response?
A score of 7 or more needs an emergency assessment by a team with critical care skills.
What is the most sensitive early sign of deterioration?
A rising respiratory rate.
What does SBAR stand for?
Situation, Background, Assessment, Recommendation: a structure for clear escalation calls.
What should be done for a NEWS2 of 5?
Urgent review by a doctor within 30 minutes and at least hourly observations.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A ward patient's NEWS2 score is 7. What response is required?
Answer: Emergency senior review. NEWS2 of 7 or more triggers an emergency response with continuous monitoring.
- Review on the morning ward round: Too late.
- Repeat observations in 4 hours: Too slow.
- Hourly observations only: Needs immediate clinical response.
- Nurse-led review only: 7 or more is an emergency.
2. A patient has a total NEWS2 of 3, but this includes a respiratory rate of 26 (scoring 3). What response is needed?
Answer: Urgent review by a doctor. Any single parameter scoring 3 needs urgent review, whatever the total.
- No action; total is low: A single red score triggers urgent review.
- Observations every 12 hours: Too infrequent.
- Critical care only if total reaches 7: A single 3 already needs a doctor.
- Discharge planning: Inappropriate.
3. Which patient should be scored using SpO₂ scale 2 of NEWS2?
Answer: CO₂ retainer with a set 88–92% target. Scale 2 is used only when a clinician has documented a target of 88–92%, usually in CO₂ retainers.
- Any patient with SpO₂ below 92%: Scale 2 needs a clinical decision and documented target.
- All patients over 65: Age is not the criterion.
- All patients with asthma: Asthma targets are 94–98%.
- Every patient on oxygen: Only those with a set 88–92% target.
4. Which finding best distinguishes early anaphylactic shock from hypovolaemic shock?
Answer: Warm, flushed skin with low SVR. Anaphylactic shock is distributive: histamine and other mediators dilate vessels, so systemic vascular resistance falls and skin is warm and flushed, often with urticaria, wheeze and angioedema. Hypovolaemic shock causes vasoconstriction: high SVR, cold clammy skin. Both cause tachycardia, hypotension, oliguria and raised lactate.
- Tachycardia above 100/min: Present in both.
- Systolic BP below 90 mmHg: Present in both.
- Urine output below 0.5 mL/kg/h: Present in both.
- Raised blood lactate level: Present in both.
5. What do the central chemoreceptors in the medulla respond to?
Answer: CSF H⁺ from raised arterial PCO₂. CO₂ crosses the blood–brain barrier and forms H⁺ in the CSF, which stimulates the central chemoreceptors. They drive about 70% of the response to raised CO₂. Low PO₂ is sensed only by peripheral chemoreceptors (carotid and aortic bodies). H⁺ and HCO₃⁻ in blood cross the barrier poorly.
- Low arterial PO₂: Sensed by peripheral chemoreceptors.
- Low haemoglobin: Not sensed directly.
- Plasma bicarbonate directly: Crosses the barrier poorly.
- Blood pressure: Sensed by baroreceptors.
References and dose sources
- Royal College of Physicians: NEWS2
- Resuscitation Council UK: the ABCDE approach
- Resus Council UK — ALS
- NICE CG50 — acutely ill adults in hospital
- Resus Council UK — ReSPECT
- Ringer's lactate (Hartmann's solution) dosing: Drugs.com: Lactated Ringer's dosage (see also our ringer's lactate (hartmann's solution) dose page)
- Piperacillin-tazobactam dosing: Drugs.com: Piperacillin/tazobactam dosage (see also our piperacillin-tazobactam dose page)
- Naloxone dosing: Drugs.com: Naloxone dosage (see also our naloxone dose page)
- Dextrose (glucose) dosing: Drugs.com: Dextrose dosage (see also our dextrose (glucose) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.