Running head: CLINICAL EXEMPLAR

Clinical Exemplar
Deanna Haxton
University of South Florida

CLINICAL EXEMPLAR

Clinical Exemplar
The purpose of a clinical exemplar is to allow the nursing student to reflect on a clinical
experience. This can allow the student to draw on their experience and apply didactic knowledge
to help improve clinical problem solving skills (ONeil, Duplock, & Willis, 2006).
ICU Experience
A 54 year old male was transferred up to the ICU after a guillotine style below the knee
amputation of the left leg. He had a history of Diabetes, hypertension, hyperlipidemia, obesity,
and Hepatitis C. The patient originally had an infection of the foot which went unhealed. His
records reported that he had not been taking medication to manage his health for over a year
because he didnt feel any better when taking the medication. During report the patient was
described as very sick and septic. The patient came up from surgery with only one 22 gauge IV
and an arterial line.
Immediately I was concerned about the limited vascular access available for this patient.
The first sign of the problem was the bleeding. The patient bled through his dressing and the
absorbant pad underneath in less than an hour. The resident was called who came and reinforced
the dressing. This slowed the bleeding but there continued to be fresh blood over the remaining
course of the shift. While the resident worked, I placed an 18 gauge IV and my preceptor
requested central lines be put in.
The next problem came with the lab values which showed a declining hemoglobin,
followed quickly by the patient becoming restless and extubating himself. At this time the
resident decided to turn off his sedation and see if he would tolerate being extubated. During this
time the patient started to pull lines and pulled out his newly placed IV and arterial line.

CLINICAL EXEMPLAR

The decision that needed to be made was what to do first; place a central line, start blood
products running, re-intubate, or investigate the bleed? Things to consider were risk to the
patient associated with central line infection, the patients O2 saturation rate, and if we had lines
available for the administration of blood products.
I was lucky that most everyone I needed was on hand. The respiratory therapist (RT) was
at the bedside setting up oxygen via a venture mask. The resident agreed it was time to get some
central lines placed. He ordered blood products and called for assistance in placing the lines.
We spoke with the charge nurse who rallied nearby nurses to assist with our other patients and to
witness the blood products for my preceptor.
The situation could have gone downhill very fast. The patients bleeding was not a fast
bleed but could potentially result in hypovolemic shock; the patients unsecured airway coupled
with sedation could lead to respiratory acidosis and hypoxia. With only a 22 gauge IV in place,
fluid resuscitation would be challenging. Several things really needed to be done at once; it was
a team effort which focused on prioritizing interventions.
In a true show of professional interdisciplinary teamwork the patients airway
management and blood gas labs were handled by the RT. Bleeding was controlled by the RN
and resident who reinforced the wound dressing. Blood bank worked to get blood products to
the bedside and the support staff assessed blood sugar while the nursing student secured another
IV and restrained the patient per orders.
When shift change came the patient had a swan and cordis introducer in place, had
received platelets and packed red blood cells, and his lab values were improved. The patients
oxygen saturation rates had been steady above 93%. His bleedings was minimal and blood gas

CLINICAL EXEMPLAR

was redrawn to verify his oxygen status while on the Venturi mask. This result led to the
decision to re-intubate and provide respiratory support.
Reflection
This experience is a reflection of how every step in the health experience directly impacts
the patients outcome. Early prediction of possible outcomes plays a key role in in the outcome
of any given situation. There were several things that could have been done better starting with
the OR team placing central lines before bringing the patient to the ICU. A second 18 gauge IV
could have been placed when the first one was. I wished I was closer to the bedside when the
patient started to move and that everything had been double secured. Things that were done well
were contacting the support we needed early. The entire ICU team worked incredibly well
together.

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References
ONeil, P., Duplock, A., & Willis, A. 2006. Using clinical experience in discussion within
problem-based learning groups. Advances in Health Sciences Education, 11(4), 349-363.
doi: 10.1007/s10459-006-9014-6