Running head: CLINICAL EXEMPLAR: REFLECTIVE JOURNALING 1

Clinical Exemplar

Stacy D. Dunham

University of South Florida

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Clinical Exemplar

Noticing

An unrestrained passenger in a vehicle going at a high rate of speed when it collided with

another vehicle. Testing revealed multiple facial fractures, a subarachnoid hemorrhage, and a

subdural hematoma with midline shift of 6.5mm, and a Grade III diffuse axonal injury (DAI). The

patient is intubated, on a ventilator, a subarachnoid bolt was surgically placed to monitor increased

intracranial pressure (ICP), receiving a continuous Propofol drip to maintain sedation, and on tube

feedings. Several medications are also available as needed (PRN), such as propranolol, fentanyl,

and Mannitol.

In the evening report the nurse stated the patient's vitals and values are generally the

following: systolic blood pressure (SBP) under one hundred twenty, heart rate (HR) below ninety-

five, temperature below ninety-nine, ICP approximately six mmHg, osmolality below three

hundred twenty, blood sugar (BS) below one hundred ten, and has normal lab values. In addition,

their pupils are unequal, have a GCS of 4 and decerebrate response to pain, with hypersecretion of

saliva requiring continuous suctioning, and regularly go through sympathetic storming, elevating

their all vitals temporarily. The nurse also reports they haven't needed to give any PRN

medications. Upon assessing the patient I saw an upward trend in heart rate with a baseline of one

hundred five, SBP of one-hundred thirty, temperature of one hundred one, respirations tachypneic

and well over the rate of the ventilator, ICP average of eight, very diaphoretic, and storming every

ten minutes or so. Otherwise, there is no further decline in GCS, pupils remain unchanged, and lab
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values aren't to be drawn for several hours.

Interpreting

I noticed there was a slow, but significant, upward trend in the patient's vitals. I had a few

initial thoughts, which were 1) this could be related to the DAI and a further degradation 2)

worsening hemorrhage 3) there is an underlying infection 4) is a response to pain. Thoughts one,

two, and three can all cause an increase in sympathetic response causing the increase in vitals and

ICP as the body attempts to compensate for effects of the injury, and a pain can also cause the same

symptoms. While this patient is in a persistent vegetative state they are not brain dead, and

therefore the body will respond to pain similarly to someone without a brain injury. To decide what

the problem may be, I did a process of elimination. One and two are put on the back burner,

because the patient isn't due for any radiologic testing until the following morning. Number three is

also on the back burner, because new labs aren't going to be drawn for a few hours, so that leaves

me with number four, a pain response. I notified my preceptor of my findings, but I didn't feel it

was appropriate to contact the doctor at this point since vitals, while elevated, weren't too far

outside the normal range and weren't critical.

Responding

While notifying my preceptor I made the suggestion to treat for pain and give a dose of

fentanyl to see if it elicits a positive response. There were orders for prn fentanyl, and this treatment

doesn't require any manipulation of the patient, and they already had a central line in place. In

addition to treating pain, if the change in vitals are caused from number one, two, three, or

unknown problem, it could still have a positive, decreasing effect on BP, HR, and respirations.
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Waiting to perform any treatment wouldn't have been appropriate, as the patient is high risk and an

increase in BP, HR can cause an increase in cerebral perfusion pressure (CPP), which will cause a

further increase in ICP and thereby worsening outcome and/or cause death. A lack of assessing and

treating pain is associated with worsening outcomes and an increase in morbidity and mortality,

however, by treating pain it has shown to have improved outcomes and shorter hospital stays

(Ayasrah, O'Neill, Abdalrahim, Sutary, & Kharabsheh, 2014). It was, however, appropriate to wait

to call the physician, and for labs and radiologic testing to be performed. If the patient's vitals and

storming decrease then we'll know if it worked.

Reflecting

Looking back on it, the most appropriate treatment was performed, and the desired outcome

was achieved. It didn't involve subjecting the patient to pain or manipulation, and wasn't invasive.

Fentanyl is also a synthetic opioid and has less side effects then opiates or semi-synthetic opioids

which may cause a significant decrease in HR, BP, and respirations, which also could cause a

negative effect and/or death. However, if a negative response occurred then naloxone is available to

reverse the effects. In this case, the patient's HR decreased to ninety, SBP to one hundred fifteen,

ICP to 5mmHG, storming was less frequent, respirations were still tachypneic but slower, and there

was no change in temperature, except when bedding removed and patient's skin exposed to room

air. Lastly, what did well was perform a thorough assessment and interpretation of the vitals, and

came up with several differential diagnoses, which helps prevent getting tunnel vision, and two of

the four were correct. I could have performed a faster assessment, as I took my time, but I feel

things get missed when moving too fast.

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References

Ayasrah, S., O'Neill, T., Abdalrahim, M, Sutary, M., & Kharabsheh, M. (2014). Pain

assessmentand management in critically ill intubated patients in Jordan: A prospective

study. International Journal of Health Sciences (Qassim), 8(3), 287- 298.