Running head: CLINICAL EXEMPLAR

Clinical Exemplar
Melissa R. Roy
University of South Florida

CLINICAL EXEMPLAR

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Introduction

According to Pacini (2006), a clinical exemplar is a story of a real patient that is told in
order to demonstrate or illustrate a nurses practice. The clinical exemplar is written in first
person and describes a patient scenario and animates how the nurse felt during the scenario, what
their thought process was, what critical thinking skills they used, how they came to their
decisions, and what actions were performed. The following clinical exemplar was a specific
patient scenario I had during my preceptorship and demonstrates exactly how I felt and the
reasons why I made the decisions I did during that moment.

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It was my second day of preceptorship and my patients were stable and doing well.
During my 1330 assessments, I noticed that my 33 week old male patients abdomen appeared
distended, but was still soft, he did not guard it when palpated and bowel sounds were present in
all quadrants. I recalled that he had not had a bowel movement on our shift yet, so I decided to
look in the chart to see when his last one was documented. His last bowel movement was charted
as large, green, and firm at 2200 the night before, so my nurse and I were not concerned at this
time. He has a NG tube placed where he receives his breast milk via enteral feedings at 38mL an
hour every three hours, which retained no residuals during checks throughout the shift.
A few hours later we began our last round of patient assessments and feedings for the day
which was around 1630. It was our 33 weekers turn to be assessed and fed and when I
approached his bedside I noticed he appeared a little off. He was laying very still, his skin tone
on his face appeared flush and he looked lethargic. I began my assessment and his vitals were all
great, but his abdomen was still distended and appeared as if someone had been pumping air into
his belly. I listened to his belly and bowel sounds were present and active in all four quadrants
and his abdomen was still soft when palpating. I then checked his residual and became
concerned. I had a 3cc syringe that filled with feed. I called my nurse over to help me assess the
situation and she received a total of 11ccs back. Since his feedings are set at 38mL and hour,
11ccs of residual is a big concern. He still has not had a bowel movement, during the shift so we
decided to call the provider.
The reason we decided to call the provider was because we already watched and waited
from our 1330 assessment and we ended up finding residual, which is now an indication that
something could be going wrong in his intestines. A common disorder in premature babies is
necrotizing entercolitis which is what my nurse thought it could be, and my thought was a

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possible obstruction since he has not had a bowel movement since 2200 and it is now 1645 and
are getting back residual. If it was either of the two scenarios, it could be a matter of life or death
for the baby as both conditions could lead to perforation of his intestines or possible sepsis which
can cause death if not treated quickly.
When the Nurse Practitioner arrived to assess the baby, she did not like what she saw.
She decided to order a full sepsis work up which included changing the baby to NPO status, IV
placement, running antibiotics, fluids, blood cultures, urine cultures, replogle to low continuous
suction, abdominal flat view x-ray, and glucose checks every 6 hours. We had two nurses trying
to start and IV, someone from lab collecting blood for the labs and glucose checks, my nurse and
I straight cathed the baby to collect urine, and another nurse was bringing supplies to the room as
needed. In this situation I would delegate by calling the lab to collect the blood for blood
cultures, call for a PCT to help calm and hold the baby still while trying to get labs and insert a
catheter, and can call for available nurses to assist so we can get the work up done as soon as
possible and labs sent off so we can receive results sooner. Since this began so late in the day and
we had to change shifts, we did not know if the patient in fact was septic, had necrotizing
entercolitis (NEC), or an obstruction until the next time we came to work. Fortunately, all of the
results came back negative and the baby is healthy. Three days later, he still did not have a bowel
movement but the concern for NEC, obstruction, or sepsis has subsided.
I definitely believe that I made the right decision suggesting that we called the provider
because we had already watched and waited, did a full focused assessment, and found that his
condition was getting worse after waiting (by having residual). My nurse and I did all that we
could from the nursing perspective and we really needed a provider to assess the baby and order
other tests to determine if something was going on. Thankfully, we did receive the desired

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outcome of the baby being healthy. It is unfortunate that we had to put the baby through that
whole work up and it turned out that nothing was wrong, but at the same time I am glad that we
did not hesitate to contact the provider, because if something was in fact wrong, the baby could
have potentially lost his life.
In this whole situation, I felt really good about my assessments. Since I saw his abdomen
was distended, I knew to listen for bowel sounds, assess if it was firm or soft, tried to determine
if he was in pain by guarding his abdomen when it was touched, and I looked in the record to see
when his last bowel movement was so I can give an adequate report to my nurse and provider.
All in all I believe my nurse and I handled the situation very well. For this situation I really dont
think there is much that I could have done better. I felt confident because my nurse was there to
support my decisions and I was able to turn to her when I found residual, but I am sure that if I
was the working nurse I would have been a little more nervous to make the call without another
pair of eyes reviewing my patient with me. All of the nurses in the NICU are always willing to
help each other and believe that they would be willing to come take a look at my patient if I felt
like something may be going on, but wasnt ready to call the provider yet. I am thankful to have
been a part of that experience and am happy the baby is healthy!

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Reference

Pacini, C., M. (2006). Writing exemplars. Retrieved from

https://www.med.umich.edu/nursing/framework/application/WritingExemplars.pdf