Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar: A Difficult Day in the ICU

Jessica Panasewicz

University of South Florida

CLINICAL EXEMPLAR 2

Clinical Exemplar: A Difficult Day in the ICU

My preceptorship in the Coronary Care Intensive Care Unit at Tampa General Hospital

was truly a wonderful learning experience. There were some days that were slow and the patients

were generally stable, and others that were so busy and hectic I could barely keep up. Pacini

(2013) describes a clinical exemplar as a story about your clinical practice that conveys

something memorable, or something you remember as important, significant, or that

comes to mind periodically. My story conveys a difficult day that I had in my

preceptorship in the ICU. It describes how I handled it and what I learned from it.

Noticing

Subjective and objective data

A 71 year-old female presented to the hospital for a scheduled breast implant removal.

She had gotten into a MVA two months prior, where an MRI revealed a ruptured implant. During

the procedure, she began to have ST elevation and went into cardiac arrest. After 6 minutes of

ACLS, ROSC was achieved. An EKG was performed and after a STEMI was noted the patient

was immediately taken to the cath lab. Her right coronary artery was stented and she came up to

us at CCU. Within 45 minutes of her arrival, the NP that was evaluating her noticed significant

ST elevation on the monitor. Once another EKG was performed, which revealed greater ST

elevation than before, the patient was rushed back down to the cath lab. Her stent had clotted, so

the patient was put on an intra-arterial balloon pump via her right femoral artery and Integrilin

was started. The patient came back to us and was determined to be 1:1 monitoring with q 15 min

vitals. The patient was intubated and on a vent. She had two JP drains, one from each breast,

secured with an abdominal binder. The patient required heparin, propofol, and pressers.
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In this situation, it was clear there was a problem. The patient had presented in good

health to the OR, but by the time she was in the CCU, she was clearly critical. Looking back at

her history, the patient seemed to be very non-compliant. After 60 years of smoking, there was

note of a suspected lung cancer in 2005 but the patient stated she didnt want to know about it.

Otherwise, the patient had no significant cardiac history. Once the patient initially came up to

the CCU there was a lot going on. The NP was showing me and two other medical students how

she was putting in an arterial line in the femoral artery. After the line was in, the NP felt

something wasnt right because of how the ST elevation looked now compared to in the cath lab

initally. Because I was not with the patient initially to see the first EKG, I wasnt aware of the

difference, but knew from the NPs assessment that this wasnt good.

Interpreting

The patient was being closely monitored by Gulf to Bay, cardiology, plastic surgery,

vascular surgery, and CT surgery. Upon taking a temperature, the patient was reading anywhere

between 95-96 degrees F and her skin felt ice cold, so I placed a bear hugger on the patient and

inserted a temp-probe foley. When I was emptying the patients drains, she was putting out a

significant amount of sanguineous drainage at about 100 ml/hr in both drains. When plastic

surgery came by, I notified them of the patients excessive drainage. I had a feeling she would

need some blood transfusions in the near future. It seemed like the patient was bleeding from her

surgery, but there was a higher amount than what is expected, which signaled to me that the

patient was in really critical condition and her body was fighting hard to keep her alive.

Responding

The patient needed close supervision and many interventions. Every time the providers

came by, I made sure to give them a status update. YeongHo et al. (2017) states that timely
CLINICAL EXEMPLAR 4

percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are

crucial in the management of a STEMI patient. The PCI was performed initially upon arrest

which was important, but because it clotted off shortly after, became concerning. I had never

seen the doctors so frustrated and confused about what to do next. The patient was also on

Integrilin and Heparin, which was necessary to prevent clot formation, but placed the patient at a

higher risk for bleeding when she was already bleeding significantly from her surgery. RT was

watching the patients vent settings and ensuring they were followed-up accordingly. At this

point, my nurse and I were monitoring the patients status closely and following the orders from

the providers. I felt there was nothing else that could be done until further progression of the

patient showed room for more interventions.

Reflecting

For this patient, I feel the right decisions were made by the care team in the moment. My

nurse and I were doing everything we needed to do in a timely manner and watching the vitals q

15 minutes. We were drawing blood frequently to assess hemoglobin and blood gases, and caring

out the necessary interventions. With the patient being so cold, it was hard to get a temperature

reading so the bear hugger and temp-probe Foley were a must. I feel the desired outcomes were

achieved as best as possible but undoubtedly this patient was crashing. I feel I identified risk

factors for this patient really well, such as bleeding precautions, changes in vitals (what to look

for in hemorrhagic or cardiogenic shock), and temperature management. I also noticed this

patients urinary output was dropping and suspected the kidneys were shutting down, which

turned out that the patient was later identified to have AKI. I feel what I could have done better

would have been to have a better understanding of some of the interventions that were being

done to her, such as the inter-aortic balloon pump, because it would have helped me to
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understand a little bit more about what to look for and how to best care for this patient. Although

I wanted to learn more in the moment, there was so much going on so I had my nurse explain to

me what she could and did my research after. Overall, I think this patient taught me a lot about

critical care and how quickly a stable patient can deteriorate. I also learned that having extensive

background knowledge before receiving a very critical patient like this is imperative to take the

best care of the patient and I will better prepare for this in the future.

Conclusion

Its no doubt that days in the ICU are unpredictable. My clinical exemplar shows just

how challenging these days can be. Although you cant plan for the challenges you may face on

the job, you can definitely be prepared for them. This day in the ICU taught me so much about

the knowledge you need to have to work in the ICU and just how vital teamwork is in the

process. It is a day that I will take with me to my future endeavors as a new registered nurse.
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References

Pacini, C. M. (2013). Writing exemplars. Retrieved from https://www.med.umich.edu/nursing-

PDE/framework/docs/writingExemplars.pdf

YeongHo, C., Yu Jin, L., Sang Do, S., Kyoung Jun, S., KyungWon, L., Eui Jung, L., & ... Ro, Y.

S. (2017). The impact of recommended percutaneous coronary intervention care on

hospital outcomes for interhospital-transferred STEMI patients. American Journal Of

Emergency Medicine, 35(1), 7-12. doi:10.1016/j.ajem.2016.09.024