Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar

Dat Le

University of South Florida

CLINICAL EXEMPLAR 2

Clinical Exemplar

Clinical exemplar is a story about a real patient, describes in detail a nurses feelings,

critical-thinking, decision-making, and thought process. A clinical exemplar illustrates the

nurses experience working with patients and how she practices in the clinical setting. A clinical

exemplar can be defined as a brief, focused narrative that places content in context for

illustration such as an exemplar of moral distress or cost-benefit analysis (Winkelman, Kelley,

& Savrin, 2012). Clinical exemplars allow nurses to reflect on past clinical experiences, develop

emotionally intelligent responses, and the significance of actions and how they influence patient

outcomes. The following clinical experience taught me the significance of teamwork, patient

advocacy, and leadership, and it details the story of a 59-year-old male with a history of

pancreatitis and possible pancreatic cancer related to gastric outlet obstruction,

Story

Patient is a 61 year-old male that was admitted on 06/01/17 for abdominal pain and

nausea and vomiting for one week. Patient had a medical history of diabetes mellitus, COPD,

CAD, and chronic pancreatitis. Night nurse gave shift report at 0800 to my preceptor and I, at

patients bedside. Patients reason for admission was report of nausea and vomiting for one

week, and patient vomited four to five times last night. Patient is on a clear liquid diet but has

been noncompliant and I noted that patient had one empty can of diet pepsi, an empty sandwich

wrapper, and cookies that have been already been eaten partially by patient, on his bedside table.

Night nurse stated in shift report that patient had an EGD done on 6/5 and results were

determined that patient has gastric outlet obstruction (GOO) likely related to the pancreatitis.

Patient has a pending computed tomography (CT) scan of pancreas to determine if patient has

pancreatic cancer. CT of pancreas was unable to complete right now because patient had traces
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of barium left in his intestines from previous barium study done on 6/6 and we are waiting for

the barium to be cleared out of the intestines. Patient also has a consult with general surgery to

evaluate for possible gastrojejunostomy.

Patient stated he felt nauseous after shift report was completed. The patients large

amount of vomit seen in the toilet was abnormal and new to me because I never seen such

copious amounts. The vomiting places him at risk for electrolyte imbalance. Patient was assisted

to bathroom, by my preceptor and I, for him to vomit. After he finished vomiting into the toilet,

patient was assisted back to the bed. Patient then began to rub his stomach and neck and

proceeded to report he had complaint of pain of an eight in his abdomen and neck. I stayed at

bedside and tried to relieve the pain by applying an ice pack to patients neck and my preceptor

administered oxygen via oxy-mask at five liters. My preceptor left bedside to retrieve IV Zofran,

call the doctor to ask for pain medication and notify the doctor about patients condition. The

attending physician was notified and immediately came to bedside to assess patient at 0800.

Doctor gave orders for IV Ativan, a now dose of 2 mg of Dilaudid IV push, a chest x-ray to be

done at bedside and to have patient NPO until he can control his vomiting. Nurse administered

IV Ativan and IV Dilaudid at 0820 and chest x-ray was completed at 0830. Patient was left in

bed in stable condition without signs of distress, oxygen saturation at 97% via oxy-mask and

patients bucket was within reach if he needs to vomit.

I made sure to look up the lab values and patients sodium was 139 and potassium was
3.4. All other lab values were within normal limits for today. Patients mental status was
monitored throughout the shift because Dilaudid was administered. Patients vital signs were
check by the certified nursing assistant at 0900 and the blood pressure was 106/55 and heart rate
was 87. My preceptor was notified of patients vital signs and patient was found in bed to be
asleep during 0900-1100.
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Patient morning medications has been held, because all were oral meds and patient is
NPO. Patient is NPO, so its also important to continue to check his blood sugar, he also has
orders for accucheck four times a day. Patients blood sugar was checked at 1130 and the result
was critically low, 67. Patients vomiting and also NPO status could have caused the low blood
sugar. The protocol for a blood sugar at that level was to administer 50% dextrose, but the unit
was out of stock at this time. Pharmacy was called at 1145 and the pharmacist stated that the
main hospital is out of D50 and it has been backordered for 1 week. The patient has a written
order for 1 mg of glucagon given subcutaneously but the package states that its only to be given
intramuscularly or IV. My preceptor notified the doctor of the situation and the doctor gave
orders at 1204 to give one liter of 5% dextrose in 0.45% normal saline at 100 ml/hr.

Patients blood sugar is critically low and we want to correct it by starting the dextrose
infusion immediately. I hung the 5% dextrose in 0.45% normal saline solution bag and started
the infusion at 100 ml/ hr at 1215 with the supervision of my preceptor and continued to monitor
the patient for any signs of hypoglycemia. Patient was in no signs of distress, alert and oriented,
did not vomit, and was asleep during 1300-1600. Vital signs at 1400 was checked by the CNA
and were within normal limits. Patients blood pressure was 112/ 65. At 1615, the task of
checking patients blood glucose was delegated to the CNA. The result was 118, and the
dextrose infusion is still running. Patient was awake and conversant, no signs of vomiting, his
pain level was assessed and patient reported its a 7 now but tolerable. Patient was in stable
condition for the remainder of the shift.
Conclusion

I advocated for my patient because I responded to the patients episode of vomiting

promptly and used my nursing judgement, along with my preceptor, to call the doctor
immediately to inform her of the situation and the doctor came quickly to assess the patient. My
nurse did well in implementing interventions early, such as, giving IV Ativan, IV Dilaudid, and
putting the patient on an oxy-mask. I observed and knew my responsibilities that I could not
administer IV push medications but I monitored my patients for adverse effects of opioids such
as hypotension. I monitored patients mental status, blood pressure, other vital signs, and blood
sugar throughout the day and looked at the trends. I would report any abnormal vital signs, lab
values, and blood sugar that the patient had, and the outcome was achieved because patients
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vital signs and mental status were stable over time. I did well in advocating for my patient and
reporting pain levels to my preceptor. I did well in letting my preceptor know about patients low
blood sugar of 67 at 1130 and hanging the dextrose infusion to correct that blood sugar. Our
outcome was achieved because the blood sugar went back up to 118 at 1600 from 67 and patient
reported no more episodes of vomiting during the rest of the shift.
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References

Winkelman, C., Kelley, C., & Savrin, C. (2012). Case histories in the education of advanced

practice nurses. Critical Care Nurse, 32(4), e1-e17. doi: 10.4037/ccn2012319