【核心監測與通報】
1. Vital Signs: Q4H/Q8H (Based on acuity).
2. Call MD/NP immediately if:
- SBP < 90 or > 160 mmHg.
- HR < 50 or > 120 bpm.
- BT > 38.5°C.
- SpO2 < 92% on current O2 support.
- GCS change or sudden onset of distress.
【水分與排泄管理】
1. Hydration: [Fluid Name] at [Rate] ml/hr.
2. Monitor I/O: Q8H/Daily.
3. Hold IV fluid if: Lung crackles, worsening pitting edema, or U/O > 2500ml/day.
4. Record Body Weight: Every morning before breakfast.
【藥物執行安全閥】
1. Lasix [Dose]mg IVP: Check K+ level and BP before administration.
2. Inotropic agents: Titrate to keep MAP > 65 mmHg.
3. PRN Analgesics: Morphine/Keto [Dose] for Pain Scale > 7; Hold if RR < 12.
【血糖與代謝控管】
1. Sugar Check: AC/PC or QID.
2. Sliding Scale (RI):
- BS 200-250: RI 2U SQ.
- BS 251-300: RI 4U SQ.
- BS > 300: RI 6U SQ and Notify MD.
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