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檢視護理師針對一位術後狀況持續惡化之個案的升級處理時間軸，然後選出最安全的管理處置。

Trend

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Time	Data
0800	BP 118/72 mm Hg, HR 86/min, alert. Abdominal drain has 25 mL serosanguineous output. Urine output is 45 mL/hr.血壓 118/72 mm Hg，心率 86 次/分，意識清醒。腹部引流管有 25 mL 漿液血性引流液。每小時尿量 45 mL。
0830	BP 98/60 mm Hg, HR 108/min. Drain has 90 mL new bright-red output. The nurse pages the surgeon and begins prescribed supportive measures.血壓 98/60 mm Hg，心率 108 次/分。引流管新增 90 mL 鮮紅色引流液。護理師呼叫外科醫師，並開始醫囑支持性措施。
0840	No response. BP 86/50 mm Hg, HR 122/min, urine output 15 mL in the last hour. The nurse pages the surgeon again.無回應。血壓 86/50 mm Hg，心率 122 次/分，過去一小時尿量 15 mL。護理師再次呼叫外科醫師。
0850	No response. BP 76/42 mm Hg, HR 132/min; the client is cool, restless, and newly confused.無回應。血壓 76/42 mm Hg，心率 132 次/分；個案皮膚濕冷、躁動，且新出現混亂。

Q1. How should the nurse interpret the overall management trend?護理師應如何解讀整體照護管理趨勢？

Expected postoperative variation that can wait for routine rounds預期的術後變化，可等待常規查房 Adequate resolution because the surgeon was paged twice已充分解決，因為已呼叫外科醫師兩次 Time-critical deterioration with an unresolved escalation gap具時間急迫性的惡化，且存在未解決的升級處理缺口

Q2. What should the nurse do now?護理師現在應採取何種行動？

Wait another 30 minutes for the original surgeon to respond再等 30 分鐘，等待原外科醫師回應 Activate the rapid-response or emergency pathway, notify the charge nurse, and use the chain of command while continuing supportive care啟動快速反應或緊急路徑、通知護理長，並在持續支持性照護的同時運用指揮鏈 Ask an unlicensed assistive person to decide whether the drainage is surgical bleeding請未持照輔助人員判斷引流液是否為手術出血

Q3. Which documentation best supports safe continuity and accountability?哪一項記錄最能支持安全的連續性與責任歸屬？

The surgeon ignored the nurse and caused the delay外科醫師忽視護理師並造成延誤 The client looked bad, so several calls were made個案看起來狀況不佳，因此打了數通電話 Objective findings, notification times and methods, persons contacted, responses, interventions, and reassessments客觀發現、通知時間與方式、聯繫對象、回應、介入措施及再評估

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