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Clinical Exemplar
Cristin Bradley
University of South Florida

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An exemplar is a story of a real patient that is told in order to illustrate a nurses experience. It describes in detail a particular clinical situation that includes the nurse's thoughts, feeling, intentions actions, critical thinking and decision-making process (Pacini, p. 1). The week of
February 19th of this year, I had a patient who was a 68 year old male quadriplegic. He was on
MRSA contact precautions. He has a history of multiple sclerosis, hypertension, atrial fibrillation, and has a peg tube. His admitting diagnosis was pneumonia, UTI and sepsis. He was on
room air with O2 saturation of 96%. He had a wet productive cough, diminished bilateral lower
lung and bilateral upper lung rhonci upon auscultation. His extremities were flaccid with decreased sensation and generalized weakness. His pulses were weak and thready plus one and his
feet were placed in waffle boots to prevent pressure ulcers and keep his heels floating. He was
receiving iron supplements, multivitamins, metropolol, zosyn, lovenox and levemir. The
metropolol is for high blood pressure, zosyn is his antibiotic, lovenox because he's bed ridden
and has an increased risk of blood clots, and long acting insulin to provide coverage in addition
to the short acting sliding scale based on his blood glucose readings. He had a language barrier
in the sense that he couldn't speak loud and clear, instead he whispered and mouthed his words.
Not many people took the time to sit there and read his lips. I spent most of my shift in his room
to provide the best care. What bothered me the most was that he didn't want to go back to the
long term care facility and no one listened to his concern.
I knew there was a problem based on abnormal patient presentation and gut feeling.
The first problem was that the patient did not want to go to the long term facility and no one listened to his concern. I put in a consult with social work to discus his options. His health surrogate lives in Canada and we were unable to reach her throughout the shift. Once the social work-

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er came in she asked me to sit with her to better understand him. When she explained that they
had arranged for him to be discharged and will be returning to the long term care facility, he
thrashed his head side to side, had tears down his face and kept mouthing NO, NO, NO. It was
very uncomfortable to watch. The social worker said, I cant reach your sister (the health care
surrogate) but you have a contract with this facility if you want to move your sister will have to
handle that. Then again he thrashed and made a whine sound. This would be an abnormal patient presentation through his reaction and determined attitude not to go back to the facility he
came from. The second issue was that the patient was on a peg tube and all medications needed
to be crushed. However, my nurse didn't explain the medications he was on just carried out her
administration. After she did one she let me handle it the rest of the day. I would sit in a chair
next to him and loudly explain one medication at a time and why he's on it. We worked out a
good system where when he understood he'd nod and blind twice which meant I could go on to
the next medication. Early he did not want his levemir or lovenox because it would penetrate
his skin. However, I explained why I thought it was beneficial to have them and what there medical purpose was. He let me give him shots the rest of the day. It was an educational issue that
was fixed through explanation and demonstration. This would be a gut reaction because I knew it
was wrong that she didn't tell him what medications he was receiving. The same care should be
given to all patients regardless of state of mind.
This facility may be the only one that will take him because of his contact precautions
and level of care he needs. He was comfortable in the hospital because of round the clock care
from attentive helping people. But we can no longer keep him in the hospital because his admit-

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ting diagnosis of UTI and sepsis has resolved. His pneumonia antibiotics end today and his
cough, lung sounds and appearance are improving.
Reflecting on the situation, I made the right decision and feel great knowing I did my part
to provide safe care to this patient especially by respecting his wishes. He is orient to person,
place and time but cannot physical verbalize due to his MS. I was glad I took the time to read his
lips and listen to his faint whispers or else this would have gone under the radar. I made the right
decision in addressing the way she administered the medication and I feel good knowing that I
caught it, changed it and implemented it because he accepted the insulin and blood thinner from
my education. However, the desired outcome was not met. He ended up returning to the same
long term facility because other facilities declined his transfer based on his current state and insurance.

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Reference

Pacini, C. M., PhD, RN. (2006). Writing Exemplars. Nurse Action Days, 1-3. Retrieved April 17,
2016, from https://www.ucdmc.ucdavis.edu/cppn/documents/bridges_to_excellence/Wri
ting_Exemplars.pdf