Nursing faculty teaching resource
Calling nurse case brief
Recognize the change
It is 1:58 p.m. on 3 East. You are Lee Harmon, RN, caring for Robert Hayes. You have just found the change below. The charge nurse is available nearby, but no emergency call has yet been made. Compare the trend and decide what help is needed immediately.
- 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.
| Observation | Earlier: 1:30 p.m. | Latest: 1:58 p.m. |
|---|---|---|
| Respiratory rate | 18/min | 30/min |
| Oxygen saturation | 96% on 2 L/min | 89% on 2 L/min |
| Heart rate | 88/min | 118/min |
| Blood pressure | 126/74 mmHg | 104/64 mmHg |
| Temperature | 100.8 °F (38.2 °C) | 100.8 °F (38.2 °C) |
The oximeter probe and signal have been checked; saturation remains 89% on 2 L/min by nasal cannula.
Exercise response pathway
For this exercise, severe breathing difficulty, saturation persistently below 90% despite oxygen, or serious staff concern requires immediate rapid response activation without provider permission. The standing emergency protocol authorizes nasal-cannula oxygen adjustment and continuous oximetry while help is summoned. Flow and target selection are not assessed.
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.