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Ask for help from peers to stay with the patient
Ask patient to calm down and explain that nothing is happening
Blood sugar check is not important in this case
Blood sugar check required
Call doctor to come immediately without describing situation because is urgent
Call doctor using ISBAR handover
Call for blood test with Doctors order
Delivery oxygen when Spo2 drops
Encourage more fluid intake when no urine output for 3-4 hours
Fluid balance monitor: Input should be monitor closely
Fluid balance monitor: output should be monitored closely
Given antibiotics as charted
Go to the next patient and ignore patients complain
Inform Doctor when blood results are back
Inform family and career with adequate education and updates
Insert catheter when needed
Lab investigations as Doctors orders
MAP should above 65mmHg
MAP should above 80mmHg
Mechanical ventilation required to reduce work of breathing
Not inform family until the symptoms well managed
Pathway and other documentations
Pressure injury prevention
Roughly observations not required because ABX already given
Sent blood culture