Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar: Identification of Possible Sepsis

Weronika Dmochowska

University of South Florida

CLINICAL EXEMPLAR 2

Clinical Exemplar: Identification of Possible Sepsis

Nursing students experience many different situations in the clinical setting during their

time in school. Writing an exemplar is a way for students to reflect on and discuss their

experiences as well as improve their understanding (Lipnevich, McCallen, Miles, & Smith,

2014). For nursing students, clinical exemplars are used in order to tell a story regarding a patient

they cared for and how the student’s actions benefited the patient. The following is a clinical

exemplar discussing a time in which I was able to identify the signs of sepsis in one of my

patients.

The patient was a 21 year old term primigravida/para (first pregnancy/birth) who came to

the Labor and Delivery triage where she had a vaginal exam and was 4cm dilated – in active

labor. She was then moved from triage to one of the delivery rooms where she came into my

care. We took a set of vitals and all of her vitals were within defined limits except for her

heartrate which was in the 120s. We looked at her CBC and noticed her WBC count was

elevated (20,000). At this point, my nurse and I realized she was possibly fighting an infection

and decided to keep a close eye on her vitals, especially her temperature. For the majority of the

shift, the patient was behaving as expecting regarding her labor and after she received epidural

analgesia, her HR went down to the 90s. I checked her temperature every 2 hours (instead of

every 4), and each time it was between 97° to 98°F. Around 1700, we noticed the patient looked

“off” and asked how she was feeling and she said she felt weird, was having difficulty breathing,

and had chest pain. She then started having full-body shivers so we took a set of vitals and she

had become tachycardic again (120-130s), hypotensive, her temp was 100.5°F, her respiration

rate was 24, and there was fetal tachycardia as well. My nurse did a vaginal exam and the patient
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was 7cm dilated with her amniotic sac still intact. I took her temperature again 30 minutes later

and it had gone up to 102.5°F.

After noticing that our patient had a change in status, we needed to notify the patient’s

midwife in order for her to get the best care possible and get lab and medication orders. We also

notified the L&D safety nurse, who is the “go-to” nurse for any non-reassuring strips or any

concerns regarding the patient’s status. After noticing that all of my patient’s vital signs changed

so rapidly, seeing that she spiked a fever, and then having her say she feels weird and start

shivering, my gut feeling was that the patient had become septic. I asked my nurse and the

midwife what they thought and they said the patient probably developed chorioamnionitis which

is an infection of the placenta and amniotic fluid. This was a highly critical situation that needed

interventions to start as soon as possible.

I told my preceptor that I think the patient might be septic and asked if we should get a

lactate level to determine the severity of the patient’s situation. My preceptor wasn’t sure so she

called the midwife and the midwife said yes to the start of the septic bundle. Sepsis is definitely a

situation in which you want to do something right away and not wait to see what happens, as the

mortality rate increases the longer you wait to begin interventions (Liu, Fielding-Singh,

Iwashyna, Bhattacharya, & Escobar, 2017). After getting the go-ahead from the midwife, we

started the sepsis bundle. For patients that are suspected to have sepsis, the Surviving Sepsis

Campaign introduced a sepsis bundle to immediately manage it. The bundle includes measuring

serum lactate level, obtaining blood cultures, administering broad-spectrum antibiotics, and rapid

administration of 30mL/kg of crystalloid IV fluids (Lester, Hartjes, & Bennett, 2018). Each step

of the bundle has been reliable at improving patient outcomes when completed together (Lester

et al., 2018). I asked my nurse if I can help with the blood draws but she said for the sake of
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time, it would be best for her to do them so I helped gather all the materials needed. We then

gave the patient a bolus of lactated ringers and hung the antibiotics with the oncoming nurse.

Because everything starting to happen right before shift change, by the time we had the

blood cultures drawn and hung the IV antibiotics, it was time to leave for the night so I do not

know what the end result was. Even though I wasn’t able to stay before the lab results came

back, starting the sepsis workup was the best decision. I believe this to be true because the

patient had met all of the criteria and even if the results came back negative, the interventions we

performed were the best care to prevent further injury to the patient and her baby. An

intervention that was successful was giving the patient the bolus of LR as her blood pressure

stabilized which was one of the desired outcomes.

Something that I did well was recognizing what could possibly be happening with the

patient. After I told my preceptor what I thought, she did not want to agree with me but figured

she would ask the midwife if she wanted us to start a sepsis workup which she agreed to. This

made me feel confident in my assessment and knowledge of patient conditions. What I could

have done better is helped the patient and her family understand what is going on in more

laymen’s terms versus medical terms as they were not in the healthcare field and were most

likely scared and confused.

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References

Lester, D., Hartjes, T., & Bennett, A. (2018). A review of the revised sepsis care bundles: The

rationale behind the new definitions, screening tools, and treatment guidelines. AJN

American Journal of Nursing, 118(8), 40-49.

Lipnevich, A.A., McCallen, L.N., Miles, K.P., Smith, J.K. (2014). Mind the gap! Students’ use

of exemplars and detailed rubrics as formative assessment. Instructional Science, 42(4),

539-559. doi.org:10.1007/s11251-013-9299-9

Liu, V. X., Fielding-Singh, V., Iwashyna, T. J., Bhattacharya, J., & Escobar, G. J. (2017). The

timing of early antibiotics and hospital mortality in sepsis. American Journal of

Respiratory and Critical Care Medicine, 196(7), 856-863. doi:10.1164/rccm.201704-

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