1) I have to make SOAPE note, SBAR, and documentation note please help me with. This is all scenario that provide me Keaton Henderson Room 301 Keaton Henderson, 42-year-old, male police officer in the neighboring city. He was shot off-duty 2 days ago trying to intervene in an armed robbery at the gas station. He has had a right thoracotomy, and has a D5W at 125 an hour. He was transferred to the floor late yesterday evening. He was shot in his right chest. His vital signs upon admission to the floor were BP 140/72, HR 78, T 98.4 F, 36.9 C, R 20, PaO2 96% room air. He has a 3-chamber water-seal pleurovac at low continuous suction with minimal drainage. His last chest x-ray shows his right lungs to be fully expanded, and the plan is to remove the chest tube in two days. Keaton Henderson Scenario 1 The patient is stable on the floor, and now needs an initial assessment. Keaton Henderson Scenario 2 The patient presses the call light. Upon entering the room, the patient asks for pain medication. Patient states that his pain is now 8/10 from 2/10. Patient denies using his incentive-spirometry today. Keaton Henderson Scenario 3 Mr. Henderson complains, 30 minutes later, that his pain is now 10/10. He is diaphoretic and pale. He complains of shortness of breath. His vital signs are now BP 100/48, P 120, R 30 and shallow, SaO2 86% Keaton Henderson Scenario 4 Rapid Response Team, RRT, arrives and they diagnose right tension pneumothorax evident by severe mediastinal shift and tracheal deviation, hypoxia, and absent right sided lung sounds. A portable stat chest x-ray has been ordered, and the RRT calls for a thoracotomy tray and 36 F chest tube. A 16-gauge angiocath has been ordered for acute decompression of the thoracic pressure Keaton Henderson Scenario 5 The 16-gauge needle insertion has relieved the pressure. The patient has stabilized and has had the new chest tube inserted. Nursing care should be: