Running head: CLINICAL EXEMPLAR 1

Formal Reflection: Clinical Exemplar

Courtney P. Whyte

University of South Florida

CLINICAL EXEMPLAR 2

Formal Reflection: Clinical Exemplar

After nearly 700 hours spent at Lakeland Regional Health, I have experienced a wide

variety of patients and care plans. Since the beginning of my clinical experience I have gone

from an individual who was nervous to go into a patients room alone, to someone who is taking

the lead in patient care and interacting with patients, their family members, and the physicians.

Being in the Emergency Department has allowed me to tune up a lot of my skills and has given

me so much confidence in myself and my ability to provide safe and competent care to my

patients. This paper will specifically look at one patient I cared for and what I learned from that

experience and how I have grown through this program.

Subjective and Objective Data

56 year old female presented to the E.R. via E.M.S from a SNF as a sepsis alert. Patient

was unresponsive on arrival and had a left gaze. Upon arrival, E.M.S. was unsuccessful in

starting an I.V., E.R. nursing staff started a 18 gauge in the left antecubital and a 20 in the right

forearm. Patient was taken to CT for a head scan, while coming out of the CT scan, her pressure

bottomed out and the patient coded. CPR was performed in CT, as well as a round of epi given,

patient stabilized and was transferred back to the E.R. The patient was then intubated and placed

on a ventilator. Due to her constant very low blood pressure, a sedative was not given. Three

minutes after returning to the E.R. the patient coded once again. CPR was performed and two

more rounds of epi were given. Patient regained a pulse and the physician began to place a

central line. While the doctor was placing a central line, four units of emergency release blood

were obtained and the level one rapid transfuser was being primed and ready to infuse due to her

hemoglobin being 4. While the doctor was placing a central line in her jugular, she lost a pulse

again. This round of compressions were completed by me, and she again regained a pulse. The
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patient was then rapidly transfused 4 units of O positive blood, and a liter of fluid. The patients

labs and ABG’s came back and her lactic acid came back at 14.9, and she was severely acidotic.

I then placed a 16 french gauge temperature foley, and her urine was clear, and yellow and the

patient had an internal temperature of 38.8 degrees Celsius. Shortly afterwards the patient was

then given 50 grams of albumin, and another two liters of fluids. The patient has a mechanical

heart valve, and was taking warfarin, her INR was 3. The patient was given vitamin K and

Kcentra to reverse the effects of the warfarin. The patient had a j-tube already in place, and when

hooked up to intermitted suction, massive amounts of frank blood was suctioned from the

stomach. This patient was a very critical patient who needed to be in the I.C.U. but was unable to

go due to not having a clean bed available. The I.C.U. doctor came down to the E.R. and

evaluated her and continued to give orders to keep her pressure up. The E.R. doctor had ordered

norepinephrine (Levophed) with the instructions to titrate it PRN, but to not exceed 15mcg per

minute. The patient was titrated up to 15 mcg per minute and her pressure was still critically low,

so the E.R. nurse called the I.C.U. doctor who gave the verbal order to titrate it up and to not

exceed 50 mcg per minute. With the patients’ blood pressure being so low and with the amount

of Levophed she was on, the nurse advocated that the patient get an arterial line placed for an

accurate constant reading. The ICU doctor agreed with the nurse, and came down to place the

arterial line. As he was preparing to place the arterial line, her pressure continued to trend down,

so he gave the verbal order to titrate the Levophed up to 100 mcg per minute. The patient was

not tolerating the arterial line procedure well so that doctor increased the Levophed to 150 mcg

per minute and requested another vasopressor. The patient was then placed on another

vasopressor called phenylephrine. Throughout her time in the ER she had multiple ABG’s

performed and was given 9 rounds of bicarb.

CLINICAL EXEMPLAR 4

How did I know there was a problem?

This patient was assigned to a different nurse, but I watched this patient come in on the

stretcher and by her appearance and sepsis alert I knew she wasn’t well. When I knew that there

was a major issue is when the nurses started to run to find blood, the rapid transfuser, and the

ultrasound machine.

Interpreting

With a core temperature of 38.8 degrees Celsius, respiratory rate of 34, constant need for

vasopressors, and a serum lactate level of 14.9 per the 2016 consensus definition of sepsis and

septic shock, this patient was in septic shock, (Thompson, Venkatesh, & Finfer, 2019). “Septic

shock is a subset of severe sepsis characterized by hypotension unresponsive to fluid

resuscitation” (Perman, Goyal, & Gaieski, 2012). With the profuse amount of blood coming from

the J-tube, and the amount of black tarry stool with a positive occult stool test, it was suspected

that the patient had a GI bleed. With the copious amounts of blood coming from the multiple I.V.

lines and central line along with lab results the patient was also in disseminated intravascular

coagulation (D.I.C.).

Responding

With this being a critical patient it was important that the E.R. staff evaluate the patients

ABC’s, rapidly establish two large bore I.V.’s, perform surveillance lab work, perform fluid

resuscitation, obtain blood and urine cultures, and rapidly administer antimicrobials, (Perman et

al., 2012). It was found that administration of appropriate antimicrobial within one hour of

identified hypotension increased the patients survival rate to nearly 80%, (Perman et al., 2012).

The 2018 Surviving Sepsis Campaign (SSC) introduced the “Hour-1 Bundle” which

recommends administration of I.V. fluids, collection of serum lactate levels, administration of

CLINICAL EXEMPLAR 5

vasopressors, collection of blood cultures, and administration of broad-spectrum antibiotics all

be performed within the first hour of care, (Thompson et al., 2019). The E.R. staff followed that

protocol by administering fluids and blood, obtaining cultures before administration of blood

products, and administering norepinephrine, vancomycin and Zosyn all within the first hour in

the Emergency Department. The I.C.U. staff initiated the D.I.C. protocol.

Reflecting

This was a very difficult case, but helped expose me to caring for a critically ill patient as

well as exposure to certain protocols. I believe that the E.R. staff did everything in their ability to

help save this patient and followed protocol and advocated for this patient. When a patient codes

3 times, is in septic shock, in D.I.C, multiorgan failure and bleeding internally, I question if we

made the right decision, but legally we had to follow the requests of the healthcare proxy. I

wonder what her quality of life will be and if she would have wanted all those extensive

measures taken.

Conclusion

Throughout this program, but especially during preceptorship I gained the confidence to

effectively communicate with my patients, their family members, and members of their

interdisciplinary team. After exposure to many different patients I believe that my “nursing gut”

has formed, especially with certain patient presentations. Throughout this program and clinical

experience I improved my time management skills, critical thinking skills, and communication

skills.. Every shift I learned something new, and as I continue my career as a new graduate nurse

I feel like I will always be learning something new. I’m excited for this new journey and believe

that this program and clinical experience created a solid foundation for my success.
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References

Perman, S.M., Goyal, M., & Gaieski, D.F. (2012). Initial emergency department diagnosis and

management of adult patients with severe sepsis and septic shock. Scandinavian Journal

of Trauma, Resuscitation and Emergency Medicine, 20(41), 1-11. doi: 10.1186/1757-

7241-20-41

Thompson, K., Venkatesh, B., & Finfer, S. (2019). Sepsis and septic shock: current approaches to

management. Internal Medicine Journal, 49(2), 160-170.

https://doi.org/10.1111/imj.14199