Observer materials

Nursing faculty teaching resource

Observer reference

Facts for the observer

Keep this reference and the worksheet together. Use the facts to check the report; do not give the caller the model answer.

Patient / location

Robert Hayes, 67 years; fictional MRN 593824; 3 East, room 318

Admission

Hospital day 2 with pneumonia; receiving prescribed antibiotics.

History / status

Hypertension; no chronic lung disease or home oxygen use. No known medication allergies. Full code.

Respiratory change

Earlier: speaking in full sentences. Latest: more short of breath at rest, accessory-muscle use and short phrases; awake and responding.

Stage 1: initial decision

Before the update, no emergency call has occurred. Look for immediate help and rapid response, staying with the patient, upright positioning and oxygen/monitoring support under the standing emergency protocol. Do not require a specific oxygen flow at this stage. Record the learner’s words; the update does not earn retrospective credit.

Stage 2: supplied actions

At 2:00 p.m.: rapid response requested at 1:58 p.m.; head of bed raised; oxygen increased to 4 L/min after equipment check under the standing emergency protocol; continuous oximetry. Charge nurse remains at bedside. Team including clinician and respiratory therapy is on its way. No post-adjustment findings are supplied; obtain current readings without delaying help.

Nursing faculty teaching resource

Observer guidance

What to credit

If the patient worsens

If the patient worsens or help is delayed, immediately alert the charge nurse and response lead.

If the patient becomes unresponsive and is not breathing normally (including only gasping), call the code team (local emergency response) and start BLS as trained; return to SBAR only when immediate care is covered.

Acceptable response plans

Credit immediate assessment by an appropriate clinician: the covering clinician, or the rapid response clinician with covering-team coordination. Confirm who, timing, and the response to worsening or delayed help through the charge nurse/response lead. Do not require covering-clinician attendance.

Credit an uncertain concern about respiratory failure or sepsis tied to findings. Do not require a definitive diagnosis. A call confirms communication, not patient improvement.

Nursing faculty teaching resource

Observer worksheet

Observe the decision and call

Patient: Robert Hayes | Guided brief | Initially unavailable receiver

Calling learner: ____________________ Observer: ____________________

O = observed as described; N = not yet demonstrated; N/A = no opportunity (explain). Note missing parts and prompts (Y/N). Use the reference. No total score.