Clinical deterioration of hospitalized adults based on nursing records: a scoping review

Objective To map in literature signs and symptoms present in nursing records that may signal clinical deterioration in hospitalized adult patients. Methods This is a scoping review, guided by JBI Reviewer’s Manual recommendations. Searches were conducted in databases such as MEDLINE, CINAHL, Web of Science, Scopus, Embase, CAPES Theses and Dissertations Portal and Google Scholar, without time or language restrictions. The results were managed in Rayyan software for selection by titles and abstracts, full text and removal of duplicates. Results The 18 studies analyzed identified 36 signs and symptoms associated with clinical deterioration in hospitalized adult patients. All articles highlighted the five vital signs as essential for detecting this deterioration, such as blood pressure, temperature, heart rate, respiratory rate, and oxygen saturation. The main symptoms observed include agitation, changes in blood pressure, changes in blood glucose, changes in breathing/abnormal respiratory signs, cyanosis, aggressive behavior, decreased urine output, abdominal distension, hyperglycemia, changes in heart rate, desaturation, shortness of breath, noisy breathing, dehydration, edema, wound exudation, bleeding, change in state of consciousness, anxiety, unwell appearance, chills, tension headache, seizure, pain, abdominal pain, chest pain, chest pain, lethargy, nausea, pallor, cold and clammy skin, rectal bleeding, signs of shock, sweating, dizziness, and productive cough. Conclusion Nursing records are essential tools for monitoring patients’ condition and guiding clinical decisions, as they reveal signs and symptoms that may indicate a state of clinical deterioration or other health conditions.