Running head: CLINICAL EXEMPLAR

Rachel Mitnick
Clinical Exemplar
University of South Florida

CLINICAL EXEMPLAR

Clinical Exemplar
A clinical exemplar is a way to celebrate our own practice and share the opportunities
with others. Harvey et. al defines clinical exemplar as a clinical situation that stands out as the
essence of nursing. They are the milestones of nursing and are the situations that are easily
recalled. We use these exemplars to connect with other nurses about our feelings about what
we do. We can learn lessons from these stories about how to approach a similar situation in a
safer more efficient manner.
Story

The patient was admitted to the hospital for heart failure exacerbation and his history
includes cardiomyopathy and gaining 7lbs in 2 days. The patient was complaining of difficulty
breathing. His vital signs were stable at the time and his blood pressure was on the low side of
normal. When the physicians did their assessment they found he had 3rd spacing with all the extra
fluid.
They decided on a bedside paracentisis as a treatment plan. They ended up taking off
5.3L of fluid. We immediately saw his blood pressure start to slowly decrease, and after a few
minutes his heart rate began to increase. There were no orders for vasopressors and the patient
was not able to lay flat let alone in trendelenburg due to chronic heart failure. I approached the
primary nurse and asked if there were any plans to keep the patients blood pressure from
dropping further. She said no and that she was about to approach the doctors and ask about it.
When the doctors came back by they said they wanted a central line placed and levophed started.
While waiting for the central line to be placed we were able to start the leveophed in the
peripheral IV. Almost immediately after starting the treatment I observed the patients blood
pressure start to increase. The patients heart rate also became stable and the physicians were
able to place the central line with out incident.
Conclusion
A patient in this situation can go from stable to critical very quickly. His mean arterial
pressure (MAP) had also started to decrease to as low as 55, which is a problem for the kidneys
and extremities not perfusing at the required amount. After the levophed was started the patients

CLINICAL EXEMPLAR

blood pressure and MAP became stable. The lessons learned from this story are that its always
important to have a plan readied and in place to keep blood pressure within normal levels when
large amounts of fluid are expected to be removed at a fast rate.

CLINICAL EXEMPLAR
References

Harvey, C., & Tveit, L. (1994). Clinical exemplars to recognize excellence in nursing practice.
Orthopaedic Nursing, 13(4), 45-53 9p.