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 |