Guided example · LTC/SNF

Respiratory Distress in LTC/SNF

O2 dropping? Wheezing worsening? Here's how to organize the provider call before the panic sets in.

You know the resident. Let us help organize the call.

A guided example for SNF, LTC, rehab, and assisted living workflows.

Respiratory · O2 check

Mrs. G · Rm 12B · 0345

Drafting
SpO2 88% on 2L NC — baseline 94% on RA
RR 28, labored, tripod positioning
Bibasilar crackles, new wheeze on exhale
Up 4 lbs this week, mild pedal edema +2

Provider call ready

"Hi Dr. Kim — Mrs. G in 12B, COPD with new hypoxia and possible CHF exacerbation. Update: I'd like to increase O2 to 4L NC, get a CXR and BNP, and give a duoneb treatment. If she doesn't improve in 30, are we transferring?"

Before you dial

What to have ready

Having these details ready helps providers quickly determine next treatment steps and transfer needs.

  • Baseline oxygen status

    Usual SpO2 on RA or baseline O2 needs

  • Current oxygen saturation

    Now + trend over the last hour

  • Respiratory rate

    Count for a full minute — don't estimate

  • Lung sounds

    Wheezes, crackles, diminished, or clear

  • Oxygen delivery method

    NC, simple mask, non-rebreather, CPAP

  • Temperature

    Fever may point to infection

  • CHF history

    Recent weight gain, edema, orthopnea

  • COPD history

    Baseline status, recent exacerbations

  • Recent illness symptoms

    Cold, flu exposure, UTI, pneumonia

  • Productive cough

    Color, amount, consistency, onset

  • Edema

    Pedal, sacral, or pulmonary

  • Work of breathing

    Accessory muscle use, tripod position, retractions

  • Mental status changes

    Hypoxia can present as confusion before low SpO2

  • Recent breathing treatments

    Albuterol, ipratropium, steroids — what helped

Having these details ready helps providers quickly determine next treatment steps and transfer needs.

Example SBAR · starting point

Worsening shortness of breath · CHF vs pneumonia

A realistic SNF/LTC example to show the shape of the call. Your resident won't read exactly like this — that's what Panic Mode is for.

SSituation

Calling about Mrs. G in Rm 12B — increased work of breathing, hypoxia, and new wheezing since 0230.

BBackground

82F, hx COPD on 2L NC at night, CHF with EF 40%, HTN, mild dementia baseline A&Ox2. No recent hospitalizations in the last 60 days.

AAssessment

RR 28, labored with tripod positioning. SpO2 88% on 2L NC (baseline 94% RA, usually 92% on 1L). T 99.6, BP 156/88, HR 102. Bibasilar crackles, new wheeze on expiration. +2 pedal edema bilaterally, up 4 lbs this week. Using accessory muscles. Mentation unchanged from baseline.

RRecommendation

Update: I'd like to increase O2 to 4L NC, give duoneb now, and get a CXR, BNP, and BMP. If she doesn't improve in 30 minutes, should we transfer to ER? And do you want steroids started empirically?

This is one version of the call. Panic Mode rewrites it around your resident's vitals, history, and what changed tonight.

Build Your Own Call
Provider call script

Word-for-word, calm under pressure.

The opening line is the hardest part. Here's one that works for respiratory distress in LTC/SNF — adapt it to your resident, your unit, your provider.

Use Dr., NP, or PA — whoever's covering tonight.

After-hours call · 0350

"Hi Dr. Park, this is Sam, RN at Riverside — quick SBAR on Mrs. G in 12B.

She's an 82-year-old with COPD and CHF, baseline A&Ox2, who's had increased work of breathing since about 0230. Normally she's on 2L NC at night and her SpO2 sits around 92% on 1L during the day. Tonight she's dropped to 88% on 2L.

Her respiratory rate is 28, she's using tripod positioning and accessory muscles. I hear bibasilar crackles and a new wheeze on expiration. She's got +2 pedal edema bilaterally and she's up 4 lbs this week. T 99.6, BP 156/88, HR 102. Her mentation is unchanged from baseline — no new confusion.

Update: I'd like to increase her O2 to 4L NC, give a duoneb treatment now, and get a CXR, BNP, and BMP. If she doesn't improve in 30 minutes, should we transfer to ER? And do you want steroids started empirically?"

Tip: mention the baseline clearly — providers need to know how far from normal this is.

Documentation tip

"Short of breath" isn't a chart entry.

Avoid charting simply "short of breath." Document the specific details that matter for both the provider and any subsequent review:

Instead of

"Resident short of breath tonight."

Try

"RR 28, SpO2 88% on 2L NC (baseline 94% RA). Labored breathing with tripod positioning and accessory muscle use. Bibasilar crackles, new wheeze on exhale. Duoneb given at 0345, O2 increased to 4L. Provider notified, CXR and BNP ordered. Will reassess in 30 minutes."

When to escalate immediately

Don't wait on these.

If any of these show up alongside respiratory distress, the call (and likely the transfer) shouldn't wait for a full work-up.

  • Cyanosis
  • Inability to speak full sentences
  • Worsening hypoxia despite O2
  • Accessory muscle use
  • Chest pain
  • Acute confusion
  • Sudden lethargy
  • Severe respiratory distress
  • Rapid oxygen decline

Trust the gut feeling. If something feels off — even before vitals confirm it — that's worth a call and likely a head-to-toe reassessment.

When the pressure is real

You've already done the hard part.

Less overthinking. More confident calls — built around your resident, not a template.