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第 5 階段 — 採取行動。PE 反應小組已評估個案，並開立治療性抗凝血處方。請將下列護理措施依最佳優先順序排列。密切相關的步驟應立即啟動，不應有不必要的延遲。

Ordered Response

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Reassess oxygenation, hemodynamics, chest symptoms, and bleeding; prepare for urgent advanced therapy if the client deteriorates 重新評估氧合狀況、血液動力學、胸部症狀和出血；若個案惡化則準備進行緊急進階治療

Maintain continuous cardiac and pulse-oximetry monitoring; verify IV access, allergies, CBC, platelet count, renal function, and bleeding-risk findings 維持持續性心電圖和脈搏血氧監測；確認 IV 管路、過敏史、CBC、血小板計數、腎功能和出血風險結果

Document the response, medication administration, reassessments, team communication, and transfer or handoff plan 記錄反應、給藥、重新評估、團隊溝通和轉送或交班計畫

Continue prescribed oxygen, position for ease of breathing, and immediately reassess SpO2, respiratory effort, BP, and mental status 繼續給予處方氧氣，安排有利於呼吸的臥位，並立即重新評估 SpO2、呼吸作功、BP 和意識狀態

Administer the prescribed therapeutic anticoagulant using the agent-specific protocol and an independent safety check when required 使用特定藥物流程給予處方的治療性抗凝血劑，並在需要時進行獨立安全查核

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