Running head: CLINCIAL EXEMPLAR

Clinical Exemplar
Jennifer Esposito
University of South Florida

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Clinical Exemplar

Throughout nursing school, I have encountered many patients and different

outcomes. Some outcomes have been great and some have ended poorly for the patient.
However, every encounter I have had taught me something about nursing or myself as a
nurse. Recently, I have had one experience that really stuck out in my head that taught me
a number of different things from the importance of thorough assessments to medication
safety. A way to convey this incident is through a clinical exemplar. A clinical exemplar is
a way to define the true nature of nursing through a certain clinical situation (Harvey &
Tveit, 1994). This clinical exemplar recounts instances of early warning, demonstrates
new knowledge, reflects on my past experiences.
When coming onto the shift in the morning, my nurse and I got report on a 59
year-old-female that was here for an acute tibia fracture that occurred two days prior from
a fall. She has a history of renal failure and has been dependent on dialysis since 2008.
The off going nurse told us that the patient was only alert and oriented to person and that
he believed this was her baseline. Upon entering the room we asked the patient her name
and if she knew where she was. She was not able to answer the question. She groaned
and only blinked. We then said her name and she groaned again. Upon further
examination of the patients chart, we learned the patient left the hospital from another
unit the day she was admitted. Upon discharge, she was alert and oriented to person,
place, and time and she had not received dialysis in 4 days. The off going nurse also
informed us that the patient was receiving Dilaudid 0.5 mg three times a day.
My instincts told me this wasnt the patients base line mental status and that the
Dilaudid was affecting her. If this were her base line mental status, they would not have

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sent her home from the hospital 2 days prior. The patients eyes seemed slow in
responsive to light and the UAP said the day prior the patient was able to talk and
respond appropriately to questions. Now, the patient is not responding to questions. In
order to make a decision on what interventions to provide to the patient, I looked at the
patients lab values. The patients creatinine, BUN, and potassium levels were critically
high. The first thing we did was put a page out to the patient nephrologist in order to get
an order for the patient to receive dialysis. After this we paged the rapid response team
and the patients medical physician who ordered an MRI, CT, and EEG of the brain to see
if the fall she had prior to coming into the hospital had an effect on her current mental
status. We held the ordered Dilaudid in order to prevent any further damage. We also
looked at the patients ABG values, which were normal. We also consulted with the nurse
manager from the floor in order to talk to the patients family regarding her status and
their concerns regarding her care. The nurse manager called the nurse manager from the
floor she was on prior in order to determine her baseline as well as talk to the patients
family regarding her prior and current status.
I believe the patient was not able to filter out the Dilaudid due to her history of
renal failure. The patient is dependent on dialysis and not receiving it in 4 days and
continuously receiving Dailaudid caused a change in her level of consciousness due to
the excess amount of medication in her system. This situation was critical because the
patient needed to be dialyzed as soon as possible in order to reduce the amount Dilaudid
in her blood. This situation made me realize how important it is to get a thorough history
on a patients condition and to not assume anything. This patient suffered due to people
assuming her current LOC was her baseline. This family suffered because they saw their

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sister, aunt, and mother being affected by an error that could have been prevented. Every
time pain medication is administered, nurses are asked the patients sedation score and if
the pain medication is making them too sedated; they are supposed to hold the
medication. That did not happen in this situation and it negatively affected the patient.
However, not the entire fault falls on the nurses. The nephrologist knew the patient was
dependent on dialysis and even after coming to see the patient and knowing she has
missed dialysis for 4 days, he did not order it for her based off the idea she might go
home that day and she could follow up outpatient.
In conclusion, it really showed me how easy medication errors can be prevented
with proper assessment, documentation, and critical thinking. If the health care team
looked deeper into the patients care, this incident could have been prevented. Standard
order sets are helpful for a lot of patients, however, for some, they add to the room for
error.

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References:

Harvey, C, V., & Tveit, L, C. (1994). Clinical exemplars to recognize excellence in

nursing practice. Orthopaedic Nursing, 13(4), 45-53.