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Situation -- Background -- Assessment -- Recommendation/Request
Scenario #1: You are receiving report on Mr. Smith, a 65-year-old patient admitted to your unit for dizziness. Mr. Smith states “I was feeling so dizzy that I almost fell at home!” Mr. Smith has a medical history of CHF, MI, and back pain. His last vital signs were 2 hours ago and they are as follows: BP 140/78, P 72 and regular, R 13, temp 98.6, oxygen sat at room air is 98%, and he denied pain.
During report, the patient care tech comes to you and states he just helped Mr. Smith off the bedpan and noticed his BM was black and tarry. You go into assess him and he states “I really don’t feel well and my belly hurts. Can I have some pain medicine?” You notice him grimacing and clutching his abdomen. You go to assess Mr. Smith and find his abdomen is distended and Mr. Smith flinches in pain when you touch him. Mr. Smith is also pale and clammy. You quickly get a set of vital signs, and they are now: BP 92/64, P 115, resp 22, pulse ox 98% on RA, temp is still 98.6.
S – Concern for GI bleed
B – Admitted for dizziness, PMH: CHF, MI, back pain
A –Abdomen is distended and painful, patient is pale and clammy, just had large black tarry stool. VS: BP 92/54, HR 115, R 22, O2 98% RA, T 98.6F.
R – I think we should get updated CBC and stat CT scan of the abdomen, are you coming to see the patient? When should I call you back with results? / after interventions?
Scenario #2: You are working in the emergency department and triage has just placed a patient in bay 3. You stop in to assess your new patient. Ms. Taylor is a 60-year-old female who is here for shortness of breath. Ms. Taylor has a PMH of CHF and is on furosemide 20mg BID, but she has not been able to refill her prescription and has gone without the medication for 5 days. Ms. Taylor states she also had a sudden weight gain of 2 pounds within the last 24 hours. You notice during your assessment; it is very hard for Ms. Taylor to speak, and she must continue to catch her breath after only a few words. You do a quick respiratory assessment and find Ms. Taylor has coarse lung sounds and is working hard to breathe. Upon further assessment, you note 2+ pitting edema in BLE. Her vital signs are HR 103, RR 25, SpO2 83% on RA, denies pain, temp 97.6F. You place Ms. Taylor on 15L NRB and note her SpO2 climbs up to 92%.
S – Ms. Taylor in bay 3 is in respiratory distress
B – History of CHF, has not taken her furosemide in 5 days
A – lung sounds coarse, cannot catch breath when speaking, 2+ pitting edema, 2lb weight gain in last 24 hours. VS:103HR, RR25, SpO2 83% on RA, placed her on 15L NRB, now up to 92%, no pain, temp 97.6F
R – would you like to give furosemide? Call RT to put the patient on BiPAP?
Scenario #3: Mr. Simpson began to have some mild chest discomfort at home 2 days ago and came into the hospital. He has been on your unit for observation. Mr. Simpson has a history of an MI 2 weeks ago and underwent PCI with stents placed. You go into Mr. Simpson’s room to begin your shift assessment. You notice Mr. Simpson is walking back from the bathroom and is short of breath. He states this started a few minutes ago, “I was just about to call you for assistance.” You assist Mr. Simpson back into his bed and make sure the HOB is elevated. You place Mr. Simpson on 2L NC and take his vitals. His vitals are as follows: HR 120, BP 100/58, R 28, SpO2 93% on 2L NC, temp 98.4F. You ask if he has any pain and he replies, “Actually yes, I have a sharp pain in my chest.” He states the pain is an 8/10 and radiates to his left arm. You call the unit secretary to place a STAT page to the doctor.
S – Mr. Simpson is having CP with SOB
B – PMH of MI 2 weeks ago, PCI w/stents
A – VS, pain, working to breathe
