Running Head: CLINICAL EXEMPLAR

Clinical Exemplar
Angelica M. Bernal
University of South Florida

CLINICAL EXEMPLAR

Black states that clinical exemplars help nurses showcase their decision making and
critical thinking skills used to define the delivery of exceptional patient care. It is important to
have exemplars because it allows the invisible work of nursing to become visible to others.
(Black, 1997). This clinical exemplar demonstrates one of the many experiences the USF
College of Nursing has given me that helped develop the skills I need to become the nurse I am
today.
My patient was in a very critical state. He was getting repeat labs done because his BNP,
Procalcitonin, BUN and Creatinine were extremely high. As I reviewed the patients chart, I
noticed that his systolic blood pressure had been in the low 100s, his diastolic had been in the
low 60s, and his heart rate had been in the 120s-130s. I then decided to look at his MAR to see
what medications had been administered and what medications had been held. I noticed that the
patient had metoprolol (Lopressor) ordered and it had been held for the previous day shift and
night shift. I looked at the notifications and narrative notes, and nothing had been documented
with a reason why it was held. After the night nurse gave me report, I realized nothing had been
done about his lab results and she did not do anything about the actions made on her part. I asked
her why she had held the metoprolol and she told me that the blood pressure had been so close to
the parameter so she did not want to risk it. So I asked her if she knew why day shift had held it
and the same excuse was given. I then asked her if she had contacted the provider about the heart
rate being so high and if so, what they were doing about it. She told me that nothing had been
done. I knew something was wrong by reviewing the patients chart and matching what the night
nurse mentioned in report. Nothing was being done about this patients condition for the past two
shifts. I wanted to ask the patient support tech what the patients heart rhythm was overnight. I
discussed my thoughts with my preceptor and asked for guidance and correction if I was wrong

CLINICAL EXEMPLAR

in any way. I also involved the charge nurse only because I knew that this issue needed to be
addressed and because I needed support in case this patients condition were to get worse. My
priority action at this time is to notify the provider of the situation. This patient is already in a
critical state and could be getting worse to the point where his care will be out of our hands and
needed the attention of a critical care nurse. His heart rate was not being controlled and he could
easily convert to an unstable heart rhythm. So I acted immediately. I knew something was going
to happen to his heart if it kept beating this fast so I put a page out to the doctor after doing my
assessment. I obtained vital signs, did my full assessment, spoke with patient support tech about
the rhythm overnight and made sure I had all my information from the chart written down. While
waiting for the doctor to call back, the patient went into A-fib with his heart rate in the 150s. I
discuss my decision making with my preceptor along with my rationales. I will know my
decisions are correct if my patient becomes stable or does not worsen. To make a long story
short, I held the metoprolol as well because his blood pressure did not meet the criteria, but I still
put the call out to the doctor (an additional time after the patient went into A-Fib) and made sure
to stay with the patient. When the doctor got back to me, he was very upset as to why the
metoprolol was being held for two shifts. Although the nurses were using their judgment by
holding it, they shouldve noticed that this scheduled medication was being held for way too
long. The metoprolol was meant to control the clients heart rate and since it was not being
administered, the heart rate began to get out of control. Contacting the HCP help me achieve the
desired outcome. The doctor came to the floor and assessed the patient. He asked for the vital
signs to be taken. Again, the patients blood pressure was still too low. He spoke with my
preceptor and myself and told me to go ahead and administer the metoprolol, but to keep a close
eye on his blood pressure. I decided to put the patient on frequent vital monitoring every 30

CLINICAL EXEMPLAR

minutes. He then gave my preceptor the order to start digoxin if the metoprolol does not help us
achieve our desired outcome. Thankfully, the patient converted to sinus tach, with a heart rate of
130-140, a little after the doctor left and later in the day he converted to sinus rhythm so no
further interventions were needed. Also, his kidneys were beginning to fail, and after speaking to
the doctor, his antibiotics were changed and orders were placed for more lab draws throughout
the patients stay at the hospital. Making this patient my priority was something I did really well.
I was extremely prepared to communicate to the doctor and act on anything that needed to be
done.

CLINICAL EXEMPLAR

References
Black, PJ. (1997). Use of clinical exemplar in performance appraisals. Neonatal Netw, 16(5), 738. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9325873