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Change in Breathing
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Inability to talk in sentences, noisy breathing, gasping, wheezing, using accessory muscles, change in breathing [26], short of breath [26], breathless [27], increasing supplemental O2 to maintain SaO2, increase in respiratory rate (just more than the day before) [26] and low SpO2 [27]
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Respiratory distress [36], breathing more labored, trouble breathing [38] and continued use of oxygen [11]
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Dyspnea [20, 21], respiratory distress [23, 24], low SpO2 [24] and fall in SaO2 [23]
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Change in Circulation
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Impaired cutaneous perfusion [26], cold feet [26], coldness [27], tachycardia [27], (new) sweating [26, 27, 39], clammy [27, 39], (quite) pale [27], new observation, just a bit paler [26], color drainage changes, dusky [27], more pale than usual, porcelain pale, just a sort of gray, loss of pink color to their skin and color draining [27]
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Cold feet [38], (new) sweating [11, 20], clammy [11], any change in color from patient’s usual one [11, 37], (quite) pale [11], pale gray, blue [11], ashen gray, sallow, change in skin color [38] and gray [31]
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Arrhythmia [20], rhythm disturbance and hypertension [23]
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Temperature
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Fever [20], rigors, febrile [23] and hypo/hyperthermia [24]
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Change in Mentation
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Confused [26], impaired mentation [26], change in mentation [26], lethargic [26, 34], vaguer, slower [26], sleepy, not making sense, less verbal [34] and sensory change in the level of consciousness [34]
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Withdrawn [11], confused [11, 38], drowsy [11, 37], lethargic [31] and sensory change in the level of consciousness [38]
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Confused [23], drowsy [23], (mental) deterioration [24] and sensory change in the level of consciousness (without a decrease in Glasgow Coma Scale of ≥2 points) [20]
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Agitation
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Agitation [26], not getting out of bed [26], uneasy, want to sit in chair instead of bed, cannot get right position, restless [26], not comfortable [26], not comfortable in or out of bed, sitting on the edge of the seat, unsettled, distressed, anxious, climbing about, wanting tablets [27], pulling catheters and tubes out, calling out, pressing the buzzer more often [27], activity level [33] and increase activating the bed alarm [34]
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Slumped in chair [11], not getting out of bed [11], not comfortable [38] and panicky [35]
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Agitation [23, 24] restless [24] and aggression [21]
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Pain
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New or increasing pain, and jaw, neck, shoulder [26] chest [26] pain combined with bleeding [27]
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(Unusual) pain [38]
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Chest pain [20–23] and headache [20, 24]
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Unexpected Trajectory
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Not progressing [26], not expected trajectory, not following recovery pattern, not responding to treatment [26], abdominal distension, not eating [26] and bleeding [27]
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Not progressing [11], abdominal distension, not eating [11] and vomiting [11]
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Nausea [21, 24], vomiting [24], bleeding [22, 23], hypoglycaemia, dizzy [22–24], unstable blood sugars [21], syncope, collapse, fall [24] and seizures [22]
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Patient indicates feeling unwell
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Feeling of impending doom [27], feeling not right, feeling unwell [26, 27], new symptom, feeling different, feeling terrible, knowing something is happening, cannot explain what is wrong, generally unwell [26], scared and patient is not like this normally [27]
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Subjective nurse observation
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Patient looks unwell [27], cannot settle the patient down, new symptom [26], does not look or seem right [27, 34], a look in the eyes, like a gaze [27], something is not right [39], patient looks terrible [33] and not patient’s normal face [34]
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Reduced motivation, neglect, not getting out of bed, not acting in their normal way [38], patient looks unwell [11], changes in mood [38], does not look or seem right [35, 37, 38], something is not right [30 ,35], patient somehow looks so ill, difference in behavior, patient is quieter, patient did not open eyes [38] and patient looks really bad [31]
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Knowing without a rationale
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Gut feeling [27], knowing something is happening, unconscious something [26], knowing something is wrong [26, 27, 39], intuition, sixth sense [37], cannot put a finger on it [27], just a feeling [27] and something does not look right [34]
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Instinct [11], just knowing [11, 30], gut feeling [11, 38, 40], knowing something is wrong [37, 40], intuition, sixth sense [39], just a feeling [38], something does not look right [40], not as expected, cannot put a label on it [40], something is a tiny bit worse [40] and sensing [36]
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