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第5階段 — 採取行動。應變小組抵達時，迷失方向的個案在拔掉監測導線後開始爬過床欄。請依序排列主要護理師的即時床邊照護循環，從第一項到最後一項，同時指派的團隊任務並行進行。

Ordered Response

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Within minutes, reassess RASS or MINDS, respiration, vital signs, delirium, and safety; escalate for refractory agitation, oversedation, or a new competing cause 在幾分鐘內，重新評估RASS或MINDS量表、呼吸、生命徵象、譫妄和安全；如果躁動難以控制、鎮靜過度或有新的競爭性原因，則升級照護

Once the immediate fall hazard is controlled and monitoring is connected, rapidly assess airway, breathing, circulation, bedside glucose, agitation, and IV patency 一旦立即跌倒危險得到控制且監測設備已連接，迅速評估呼吸道、呼吸、循環、床邊血糖、躁動程度和靜脈通路暢通性

After the first benzodiazepine dose, give parenteral thiamine and ordered magnesium or fluid replacement while the team continues the differential evaluation 在第一劑苯二氮平類藥物給予後，給予腸道外硫胺素和醫囑的鎂或液體補充，同時團隊繼續進行鑑別診斷評估

Stay with the client, stop the attempted fall, direct one-to-one observation, reconnect continuous oximetry and cardiac monitoring, and ready resuscitative equipment 留在個案身邊，阻止其嘗試跌倒，指導一對一觀察，重新連接連續血氧飽和度監測和心臟監測，並準備好急救設備

Using the immediate assessment findings, administer the prescribed IV benzodiazepine under the delirium protocol while watching ventilation 根據即時評估結果，依據譫妄處置醫囑給予靜脈苯二氮平類藥物，同時監測通氣

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