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Victoria Clayton Clinical Exemplar

Victoria Clayton

University of South Florida

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Introduction

According to an article from the Neonatal Network, a clinical exemplar is a tool that

exemplifies all that encompasses nursing: critical thinking, making clinical judgments and skilled

decision-making. Through these aspects, quality patient care can be delivered (Black, 1997). The

following narrative briefly describes a situation in which I learned to make clinical judgments

during my fifth semester in nursing school. I spent 180 hours on a progressive care unit working

alongside some of the most skilled nurses I have ever met. This particular patient case centers

around making clinical decisions during a respiratory distress situation.

This patient had come to the hospital for his weekly paracentesis. When my preceptor and

I came to assess him in the morning, two days after an attempted paracentesis, he stated he was

in pain, 8 out of 10. He complained about a new onset cough. In report from night shift, we were

told his lungs were clear, yet diminished. Once morning vitals were taken, we were notified by

the tech that his oxygen saturation was in the 70s. Auscultating his lungs we heard rhonchi and

wheezing. Initially, the first line intervention was to increase the oxygen to high-flow. After that,

his saturation hardly improved, so I put him on a non-rebreather mask for 100% oxygen. Only

after that did his saturation improve to 91%. We ordered a chest x-ray, an EKG, a lactic acid, a

troponin, and ABGs were all ordered STAT to get to the underlying cause of his new-onset

respiratory distress.

At this point, the most important thing to do while we were figuring out what the

underlying cause of his respiratory distress was to make sure he was taking breaths and to stay

with the patient. The patient was incredibly anxious and kept asking questions and talking, which

did not help with his breathing. I took it as my responsibility to stay near him and remind him

that he needed to calm down to help his breathing.

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The best decision in this case was to consult rapid response and have him transferred to

ICU where his breathing could be better managed. Additionally, he needed to have the rest of the

fluid build-up drained via paracentesis. His respiratory distress, from the chest x-ray did reveal

pulmonary edema.

Conclusion

We did successfully transfer the patient to ICU, and he did have the fluid drained from his

lungs. I did my best to remain calm, despite the fact that it was only my second day in clinical

with my new preceptor. I stayed with my patient through the whole process and tried to reduce

his anxiety to improve his breathing. We were able to transfer him in a timely fashion, though.

However, we did find out that within a few hours of being in ICU, his cardiac function decreased

and he coded. He was then intubated and placed on five cardiac drips. We were grateful that we

transferred him in time so he could be well managed and taken care of in ICU.

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References

Black, P. (1997). Use of the clinical exemplar in performance appraisals. Neonatal

Network, 16(5), 73-8.

Kane, C. & York N.L. (2012). Trends in caring for adult respiratory distress syndrome patients.
Dimens Crit Care Nurs., 31(3), 153-8.

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