Escalation must follow the patient's orders and agency policy; the following are representative thresholds.
🚩 Red flags — escalate
Severe dehydration with hemodynamic change (marked tachycardia or symptomatic hypotension) — urgent or emergency evaluation.
An inability to take in or retain fluids — urgent evaluation.
Fluid overload with respiratory distress or pink frothy sputum — activate emergency response (911) for acute pulmonary edema (detail in Cardiovascular and the CHF overlay).
Symptoms of a significant electrolyte disturbance — new confusion, severe weakness, or palpitations — urgent evaluation.
High ongoing fluid losses the patient cannot keep up with — provider notification for a plan.
Reduced urine output with other signs of deficit or renal change — provider notification (detail in Urinary / Renal).
