CLINICAL EXEMPLAR 1

Final Clinical Exemplar

Emery Horvath

College of Nursing, University of South Florida

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Final Clinical Exemplar

During my time on a renal/urology medical-surgical unit, I experienced a variety of

patients with different diagnoses, prognoses, and interventions. Through this experience, I

learned to quickly identify different disease processes and apply my pathophysiologic

understanding of the situation to my nursing care. A particular patient comes to mind when

reflecting on my preceptorship experience due to their medical complexity and length of stay on

the unit.

Clinical Situation

The patient that stands out to me presented to the emergency department reporting altered

mental status after starting a new antibiotic. When assessed the patient’s blood glucose was

reported at eight and immediate glucose restoration was started. The patient has a history of

recent COVID-19 infection, hyperlipidemia, hypertension, diabetes mellitus, chronic obstructive

pulmonary disease, and chronic kidney disease. After about a month in the hospital, the patient

was now on the unit. The patient was nonverbal, reacted minorly to physical stimulation but not

to commands, had a tracheostomy to maintain respiratory status, a PEG tube providing her

nutrition, a rectal tube for incontinence, and perineal skin breakdown, a right IJ for hemodialysis

access, and a newly formed left AV fistula. While treating her for multiple nights for multiple

weeks the patient would spike fevers in the 103 range that would be controlled by antipyretic

medication. Additionally, there was not a clear goal for this patient’s care, the neurologist that

was consulted attributed the patient’s mental status to likely hypoglycemic encephalopathy or

perhaps a long-term effect of COVID-19 infection. Nephrology was consulted to manage the

patient’s renal insufficiency. Overall, no one on the care team had solutions and the conversation
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amongst professionals was moving towards palliative and end-of-life care, however, this was not

what the out-of-state family wanted.

Decision Making and Managing Care

A priority of this patient’s care was maintaining a patent airway. This was especially

important because the patient would often pull the oxygen mask off their trach and had secretions

the patient could not clear on their own. My preceptor and I implemented multiple things to

maintain the patient’s respiratory status. Primarily we assessed the patient’s breath sounds,

suctioned secretions when necessary, and frequently checked to ensure their oxygen remained in

place. Furthermore, the use of a multidisciplinary team was especially helpful in maintaining this

patient’s airway (Bedwell et al., 2019). Respiratory therapy would administer breathing

treatments, suction the tracheostomy, and clean the tracheostomy. My preceptor and I would also

suction, when necessary, monitor oxygen status, and reassess the patient’s needs. The unlicensed

assistive personnel would perform vital signs and their patient rounds. All together this team

made managing a medically complex patient much more approachable.

One thing I struggled with during care for this patient was understanding how the patient

ended up in the condition they were in. Researching hypoglycemic encephalopathy helped me

gain some clarity on what likely had caused the patient’s mental status. Studies have shown that

the blood glucose level and length of time spent hypoglycemic can be correlated with varying

levels of consciousness and have sometimes been related to elevated body temperatures

(Saikawa et al., 2019). This information helped me better contextualize what was happening to

my patient and understand how they were similar to and different from a standard hypoglycemic

patient.
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An additional complicating factor while caring for this patient was the family dynamic.

The patient was by themself, they did not have any spouse or children, and their next of kin was

a brother who lived in Ohio. This meant that decision-making and difficult conversations were

difficult to have. Further complicating the situation was a family friend who had been reporting

changes in mental status to the brother which were inaccurate. This meant the brother was

making decisions about delaying the end-of-life conversations due to incomplete information. I

found myself feeling limited by numerous factors here. Being on night shift we were not the ones

expected to have those conversations and because the brother was out of state his perspective on

the situation was based on short video calls and seeing his sibling and speaking with the patient’s

nurses and the family friend. Overall, it was difficult to objectively be able to see the larger

clinical picture but be limited in my ability to communicate that to a family member.

Patient Outcome

Ultimately this patient died. The patient became hemodynamically unstable and was

transferred to the ICU where the patient ultimately was unable to be resuscitated. This death was

challenging both because of the complicated and frankly poor clinical picture and because of the

connection I felt to this patient after caring for them over an extended period of time. Caring for

this patient emphasized the importance of caring for the whole person, even when they may not

be able to interact like we are often used to.

Conclusion

I grew a lot of a nurse through taking care of this patient. The complexity of the case

made me shift through copious information and find relevant details. The devices keeping the

patient alive allowed me to practice managing lines and drains that I had not experienced before.
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And the mental status of the patient allowed me to practice compassionate care even when I am

not sure the patient is aware of it.

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References

Bedwell, J. R., Pandian, V., Roberson, D. W., McGrath, B. A., Cameron, T. S., & Brenner, M. J.

(2019). Multidisciplinary tracheostomy care. Otolaryngologic Clinics of North America,

52(1), 135–147. https://doi.org/10.1016/j.otc.2018.08.006

Saikawa, R., Yamada, H., Suzuki, D., Amamoto, M., Matsumoto, Y., Funazaki, S., Yoshida, M.,

Toyoshima, H., & Hara, K. (2019). Risk factors of hypoglycemic encephalopathy and

prolonged hypoglycemia in patients with severe hypoglycemia. Journal of Clinical

Medicine Research, 11(3), 213–218. https://doi.org/10.14740/jocmr3728