300
Increased confusion, difficultly arousing, slurred speech, coughing, gagging, delay in swallowing, breathing more quickly, shortness of breath, labored breathing, nasal flaring, color changing, high pitched sounds while breathing, emesis (vomiting), blood in the stool, drainage from nose, eyes, wounds, stomas, catheters, urine that is dark and has a foul odor, urinating more often with little urine output, scrapes, cuts, bruising, rashes, bleeding, lips and gums that are not pink and moist, bleeding gums or lips, foul smelling breath, suspicious odors (sweet smelling, chemical, feces, etc) if individual gags excessively or coughs when brushing with a suction toothbrush, discoloration of nails or nail beds, changes in mood, behavior, crying, screaming, increased irritability, changes in gait (unsteady or weak), discomfort while walking, swelling, decreased in normal range of motion, injury or incident.
What are signs and/or symptoms that we report to the Nurse?