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Clinical Exemplar
Brittney Gervasi
University of South Florida
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Introduction
According to Harvey & Tveit (1994), a clinical exemplar is a nurses account of a clinical
situation expressing his or her own thoughts, feelings, critical thinking processes, interpretations,
and actions. The following account is a clinical exemplar of mine from this past year during my
preceptorship in the CCU/CICU.
Exemplar
The patient was a 57 year old male with Stage 3 testicular cancer in the CCU. He was
transferred to the CCU from the MICU due to his severe hypertension with the systolic ranging
from 150-200 over the course of a few days. He was on dialysis three times a week and would
become lethargic afterwards. Hes also anemic with a hemoglobin level of 7.5 post-transfusion.
He also has been exhibiting severe diarrhea for the past two weeks. The patients baseline was
him only oriented to self and would begin pulling on his lines when agitated.
During an episode of severe confusion, the patient became very agitated and pulled off his
O2 and would not allow us to put the NC back on. His O2 saturations were ranging in the 80s
and occasionally dipping into the 70s as he started to go into respiratory distress, so we tried a
Venturi mask but he would not tolerate that near his face either nor any other oxygen devices.
This was my second day with the patient, so I knew his presentation was a change from his
baseline. The first day, he was on room air with O2 saturations in the high 90s, and the second
day he had been on 2-3L of humidified oxygen all day with saturations in the high 90s.
After trying multiple different methods of oxygenation without success, the attendings
team needed to be notified. Depending how long his low saturations last, the situation can
become very critical as his organs arent being perfused well. His kidneys are arguably in the
most danger as theyre already functioning less than adequately. We did do something the
moment we saw his saturations dropping by trying different methods of oxygenating the patient
and calming him simultaneously. We know if were making good decisions if his saturations are
improving, and we couldnt get them above 84-85% for longer than a few minutes. The charge
nurse was alerted and was participating in the situation. The critical care team was also notified,
and they decided to intubate the patient to protect his airway and his saturations immediately
improved. Studies show that patients who are in acute respiratory distress and intubated early, as
this patient was, have better outcomes than patients intubated within the next three day
(Kangelaris et al., 2016). The patients intubated early had a 56% lower mortality rate 60 days
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later than the patients intubated within the next three days following the acute respiratory distress
(Kangelaris et al., 2016).
Conclusion
We did make the right decision, because we started out with the least invasive methods of
improving his saturations and adapted as the situation progressed. We also achieved the desired
outcome, and the patient stabilized post-intubation and throughout the next night shift. What I
did really well was addressed the situation immediately as it emerged and progressed with my
nurse and the other team members on the floor. What we could have done better perhaps would
be to suggest intubation earlier.
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References

Kangelaris, K. N., Ware, L. B., Wang, C. Y., Janz, D. R., Hanjing, Z., Matthay, M. A., & Calfee,

C. S. (2016). Timing of Intubation and Clinical outcomes in Adults with ARDS. Critical

Care Medicine, 44(1), 120129. http://doi.org/10.1097/CCM.0000000000001359

Harvey, C.V., Tveit, L.C. (1994). Clinical exemplars to recognize excellence in nursing practice.

Orthopedic Nursing, 13(4), 45-53.