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Decrease in LOC
New agitation/delirium
Repeated/Prolonged seizures
Acute Neuro changes
SBP <90 despite tx
HR > 130
HR < 40
Chest pain
Respiratory distress
Threatened airway
RR > 28
RR < 8
O2 < 90
Difficulty speaking
Temp > 100.4 or < 96.8
SIRS: 2 or more & new for patient
o O2 < 32
o Leukocytosis > 12,000 or > 10% bands
o Leukopenia WBC < 4000
o HR > 90
o RR < 28
Suction: 80-120 (oral/trach); 40-60 (Purewick);
Tele DC: (-) cardiac enzymes (for chest pain); No dysrhythmias after 48 hrs of suspected dysrhythmias; (-
) MRI on Stroke protocol; 24 hrs post pacemaker insertion with no arrythmias; 24 hours post-op with no
critical dysrhythmias; No IV meds needing tele; Pt comfort care; Discharge
Tube feeding: Put back if < 350cc; If >350 cc, replace up to 300 cc
Urinary Catheter: If voided in last 4-6 hours ok; If < or = 180 in 4-6 hours; Check urination within 2 hrs of
PVR <300-500; Straight cath if PVR > or = 300-500; Repeat PVR in 4-6 hrs to determine straight cath;
Report if still > or = 300-500; If voided > 180 in 4-6 hrs = Good!