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Clinical Exemplar in Nursing Practice

Taylor Brashears
University of South Florida
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Throughout one’s nursing experience, that are many challenging situations that arise.

These situations require substantial critical thinking skills and knowledge. A clinical exemplar is

a “narrative documenting the performance of acts requiring substantial specialized knowledge,

judgment, and nursing skill” (Koteles, 2007) in which a nurse may write to share their

experience. This semester, I was in a situation that challenged my skills and thinking by having

to make decisions and recommendations that could have possibly affect the future of one’s life.

A 48-year-old female presented to the hospital due to one month of worsening abdominal

pain and distention associated with peripheral edema, orthopnea, early satiety. The patient

described the pain as constant, moderate to severe, and worsening over time. A MRI performed

revealed lesions on the left hepatic lobe, which raised concern for an infiltrative tumor. From the

time of admission, the patient had become less alert and sleepier. During the shift, the patient

went down for a biopsy of her liver, but it was not performed due to her unstable vitals. Her

blood pressure was 88/53, her respiratory rate was 22, her heart rate was 116, and her oxygen

saturation was 95% on room air. I had a feeling there was a problem because of the signs of

septic shock. The vital signs along with the decreased level of consciousness all pointed to

symptoms of this. In order to make a decision, I needed to perform blood work in order to

determine the patient's lactic acid and bilirubin levels. The attended physician was notified of the

patient's status and the rapid response team was also automatically notified through the computer

system's alert system due to her vital signs. This was an extremely critical situation because not

treated immediately and aggressively, the result could be death. This is a situation in which

action is required now and cannot be put off. If she is in septic shock, her status could rapidly

deteriorate and irreversible damage could occur. When I was first made aware of her vitals, I

took the lactic acid level and a bilirubin level once the orders were given. After that, I contacted
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the doctor, notified her of what was happening, and recommended putting her on fluids to raise

her blood pressure. This recommendation is back up by many studies, since “the classic

physiologic rationale for fluid resuscitation in sepsis is to restore intravascular volume, cardiac

output, and oxygen delivery” (Semler & Rice, 2016). The lactic acid and bilirubin levels returned

as within the normal limits. The fluids raised her blood pressure and lowered her heart rate.

Due to my actions and thinking skills, I was able to determine that this patient was not in

septic shock and did not need lifesaving interventions. If this patient had been in septic shock,

my interventions would have determined this and have increased her likelihood of survival.
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References

Koteles, B. (2007). Clinical exemplar blues. Nursing, 37(1), 8

Semler, M. W., & Rice, T. W. (2016). Sepsis Resuscitation: Fluid Choice and Dose. Clinics in Chest
Medicine, 37(2), 241–250. http://doi.org/10.1016/j.ccm.2016.01.007