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Clinical Exemplar

Nicholas Travis

University of South Florida College of Nursing

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Clinical Exemplar

A clinical exemplar is a first person story of a healthcare providers experience with a

clinical situation. The story describes the situation in detail and includes involved emotions,

thoughts, concerns, and actions. The following is a clinical exemplar detailing a critical patient

that I cared for in the Neurological ICU during Preceptorship.

The patient came to the hospital because of a VP shunt infection/breakdown. The

patients VP shunt was becoming exposed due to skin breakdown and he got an infection. He

had the shunt surgically removed and an EVD was placed. The patient was sent to the Neuro

ICU following the surgery and was doing well until around 0600. At 0600 the night nurse noted

that the patient had increased work of breathing. She went in to assess him and he was not

responding. The nurse contacted the provider, who was on the way when I arrived. The

providers only over the phone request was that RT draw a blood gas. The nurse quickly gave my

preceptor and I report and the provider arrived shortly after.

It was apparent from the moment I saw the patient that there was a problem. Before even

walking into the room, I could tell that his work of breathing was increased and not sustainable.

He was not responding to questions and had decreased movement on the left side. In addition, he

had a right-sided gaze. When I touched the patient he was extremely diaphoretic and ashen. The

patient had an obvious abnormal presentation and was presenting with signs and symptoms of a

stroke.

No other information is really needed to make a decision. It is clear that the patient is

decompensating quickly and cannot protect his airway/maintain this level of work of breathing.

The provider was already notified and on the way. The most important person to notify is

respiratory therapy, as they must be present at the bedside during the intubation. The charge

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nurse should also be notified so they are aware of what is going on and can send other nurses to

help if needed. There are multiple possibilities of what could be happening to the patient. He

could be having a hemorrhagic stroke, a thrombolytic stroke, a TIA, a shunt malfunction,

increased ICP. What is known is that the situation is critical and interventions must be quick.

We clearly needed to do something now, waiting and watching could prove to be detrimental to

the patient. Actions that are necessary are additional IV access, induction and sedation,

intubation, and a CT scan. Evidence has shown that the faster thrombolytic stroke patients

receive treatment the better their prognosis. Thrombolysis within 60 minutes of arrival at the

hospital is recommended for strokes that occur outside of the hospital environment (Threlkeld,

Cole, Martin & Singh, 2017). The fact that this patient is already in the Neuro ICU places him at

an advantage and improves his changes of expedited treatment. You will know that you are

making the best decision because the research supports the need for quick imaging and rapid

treatment. The deicision to intubate, in my opinion was a correct one. The work of breathing was

not sustainable (especially if we were to lay the patient flat for a CT/MRI) and he cannot protect

his airway. The intubation will be done by the provider and RT. You can delegate one nurse to

retrieve and draw up meds, delegate one nurse to start IV access, and delegate the unit secretary

to notify transport that the patient needs a STAT CT. In addition, due to the time of day you can

(and we did) have another nurse check in on our other patient.

This particular situation did not go as planned. I established IV access, the patient was

sedated and paralytics were given, the intubation went as planned, and the patient was

transported to CT scan and later got a MRI. However, one of the residents and the radiologist

read the images wrong and did not realize that the patient was having a thrombolytic stroke. It

took hours for another neurologist to see the scan and realize what had happened. As nurses, I

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feel as though we did well. We did frequent neuro checks, monitored the patients vitals, and

administered medications as needed. We frequently updated neurology of the patients

neurological status. What could have been done better in this situation was the recognition of the

stroke. The patients prognosis was severely affected by this mistake and he will likely face long-

term debilitating symptoms.

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References

Threlkeld, Z., Kozak, B., Cole, S., Martin, C., & Singh, V. (2017). Collaborative Interventions

Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in an Urban, Public Hospital

(P4. 270). Neurology, 88(16 Supplement), P4-270.

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