Temperature is above normal range (ref: 36.5–37.0 °C).
Recorded value: 45.0 °C
Fever: consider infection; assess for sepsis if unstable.
High blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg).
Recorded value: 180 mmHg systolic; 120 mmHg diastolic
High BP: recheck; manage hypertension per protocol; assess symptoms and end-organ concern.
Respiratory rate is above normal range (ref: breaths per minute).
Recorded value: 33.0 /min
Tachypnea: assess for respiratory distress, fever, acidosis; consider oxygen.