Running head: CLINICAL EXEMPLAR

Clinical Exemplar

Robert Williams

University of South Florida
























CLINICAL EXEMPLAR

Clinical Exemplar
According to the Mountain State Health Alliance (2014) a clinical exemplar is
defined as, A first person story written by a nurse that describes a specific clinical
event or situation. A clinical exemplar allows for a visual of the nurses current
clinical practice in a way that can be readily examined by other health care
professionals. This example of current practice not only allows for the nurse to
reflect on things he or she may be doing well, but can also provide insight into areas
that one can be improving on. Lastly, the exemplar can be a useful tool for
advancement in the clinical setting since it allows for a first person view of the
nurses current routine, skills and problem solving abilities.
I finished up the second half of my preceptorship hours at Sarasota Memorial
Hospitals cardiovascular intensive care unit (CV ICU). While working day shift
during the second to last week of my preceptorship, my nurse preceptor and I
received a male patient from open-heart surgery. It was around 1:30 P.M. when the
patient finally arrived to us from surgery and was placed in our ICU unit. Two
nurses and the nurse anesthesiologist came up with the patient from surgery to help
get the patient settled in and to inform us of how things went during the operation.
Also in the room were my nurse preceptor, a fellow nurse in the CV ICU and myself.
The nurse anesthesiologist did not report of anything adverse that happened during
surgery, and also informed us that the patient had not been given any blood
products. Upon getting the patient hooked up to all of the monitors we had set up in
the room, the patient was severely hypotensive. In discovering this, we decided to
bolus the patient with fluids and titrate up on his epinephrine, while we waited for
CLINICAL EXEMPLAR

initial labs and the surgeon to decide what course of action we were going to take.
Respiratory therapy came in to draw blood gases and also to get the blood necessary
to send down to get our initial labs. The immediate results of the blood gases
showed that the patients hemoglobin was 6.5. This seemed to confirm the idea that
the patient was suffering from fluid volume deficit and also that he most likely
needed to receive some blood. Upon telling the surgeon of the results, he said that
he did not trust blood gases and would wait until the initial labs came back. In the
mean time, we continued to bolus fluids and also gave the patient some albumin to
continue to try and reverse the hypotension. After a short period of time the initial
labs came back and the hemoglobin was found to be 6.9. Essentially very similar to
the blood gas result, and now the surgeon decided that we could go ahead and give
the patient two units of packed cells. This was started immediately and the blood
was infused into the patient about as quickly as we could get it inside of him. After
the blood was finally all transfused and some time went by, the patients pressures
started to trend in the right direction. We had gotten the patient into a more stable
condition, and the next direction to take was to try and start weaning the patient
back off of his sedative medications in order to try and extubate. It was brought to
our attention that the last time this patient had gone under anesthesia that he
became agitated in the awakening period and it was difficult to extubate. As we
began to ease the patient into the awakening state, it became clear to us that the
patient was getting agitated as he had done in previous surgeries after coming off of
anesthesia. In realizing this, we decided that it was best to keep the patient in a
sleeping state as this time, seeing that we had just gotten him into a more stable
CLINICAL EXEMPLAR

condition. We did not want to rush the awakening of the patient and risk his current
condition that he was in. At this time, we decided that it was okay for the family to
come in and see the patient. Upon their arrival, we explained to them that the
patient was in a more stable condition, but that when he had first arrived we did
have to use some interventions in order to get him to where he was. We also
explained that he had become a little agitated as we started to wake him up and that
we were going to keep him sleeping for a little while longer. After explain this, we
allowed the family to visit and see the patient for a few minutes, but told them that it
was best if they continued to let him sleep for the time being, and to come back to
see the patient in a few hours. The family was accepting of this and they left the unit
while we continued to keep the patient under a watchful eye.
This clinical situation was one that became intense very quickly, but was
resolved effectively due to very timely decision making. The time most immediate
after a patients arrival from open-heart surgery is generally always the most critical
period. I have learned a great deal from these experiences in the CV ICU, and this
day was an especially good learned experience for me as well. These patients more
often then not have had some kind of new valve or graft placed in the heart, and
their pressures are extremely important in making sure the new parts stay working
optimally. During this particular situation and experience, I thought that the
decisions that were made and actions taken went extremely well. Quickly getting
the patient fluids and titrating his medication were both essential in helping
stabilize the patient, while waiting for labs and the okay from the surgeon to give
the patient blood. The only thing I really would have hoped to do differently would
CLINICAL EXEMPLAR

have been to start at least one unit of blood after the initial blood gas reading came
back. This did not happen, as the surgeon did not want to trust this initial blood gas
reading. Although everything ended up working out, I believe that a quicker action
in that area would have only improved the patients condition sooner.



















CLINICAL EXEMPLAR

Reference
Mountain State Health Alliance. (2014). Clinical Exemplars. Retrieved July 14, 2014,
from http://www.msha.com/Uploads /files/Nursing
/BESTClinicalExemplars.pdf