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Change in breathing
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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
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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
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Restless and/or anxious
|
|
Pain
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New pain and/or increasing pain
|
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No progress
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No progress and/or abdominal distension and/or nausea and/or bleeding and/or dizzy and/or fall and/or hypoglycaemia
|
|
Patient
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Not feeling well and/or feeling of impending doom
|
|
Subjective nurse observation
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Change in behaviour and/or does not look good and/or a look in the eyes, like a gaze
|
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Knowing without a rationale
|
Gut feeling and/or knowing something is wrong
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