Professional Documents
Culture Documents
Clinical Exemplar
Nicholas Travis
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Clinical Exemplar
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
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
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
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
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
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-
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References
Threlkeld, Z., Kozak, B., Cole, S., Martin, C., & Singh, V. (2017). Collaborative Interventions
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