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Table 4 Thirty seven signs and symptoms underlying worry summarized in 10 indicators

From: Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review

Indicator

Underlying signs and symptoms

Change in breathing

Noisy breathing and/or short of breath and/or no full sentences and/or accessory muscles and/or increasing supplemental O2 to maintain SaO2 and/or increase in respiratory rate

Change in circulation

Colour and/or clammy and/or coldness and/or impaired perfusion and/or colour drainage changes and/or hypertension and/or arrhythmia

Temperature

Rigors and/or fever and/or hypothermia

Impaired mentation

Lethargic and/or confused and/or sensory change in level of consciousness

Agitation

Restless and/or anxious

Pain

New pain and/or increasing pain

No progress

No progress and/or abdominal distension and/or nausea and/or bleeding and/or dizzy and/or fall and/or hypoglycaemia

Patient

Not feeling well and/or feeling of impending doom

Subjective nurse observation

Change in behaviour and/or does not look good and/or a look in the eyes, like a gaze

Knowing without a rationale

Gut feeling and/or knowing something is wrong