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Running head: CLINICAL EXEMPLAR

Clinical Exemplar
Willamina Folks
University of South Florida

CLINICAL EXEMPLAR

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Clinical Exemplar

A clinical exemplar of a 64 year-old male patient will be discussed. An exemplar is a


story of an actual patient that is voiced in order to illustrate an experience I had during my
preceptorship in the Medical Intensive Care Unit (MICU). This is a memorable situation that has
significance in improving my critical thinking skills and decision making. Throughout this paper
I will be describing and discussing subjective and objective findings, feelings about the situation,
an intervention initiated, and critical thinking and decision-making skills.
The Story
A 64 year old male patient presented in the Emergency Department (ED) due to a fall and
blood found in stool on 11 August 2015. The patient was transferred from an inpatient medical
surgical floor (9A) to the Medical Intensive Care Unit (MICU) due to respiratory distress while
on automatic continuous positive airway pressure (CPAP) resulting in a stat intubation. The
patient has a history of Down Syndrome, a Pacemaker, chronic aspiration, multiple deep vein
thrombosis (DVTs). Plan of care was explained to the patients sister who was at the bedside.
Subjective and objective data was gathered throughout the shift. The patient Glasgow
Coma Score (GCS) remained at a 10, with scores normally ranging from patient to patient 3 to
15. The GCS was a good indicator of the patients mental status. The patients anterior and lateral
breath sounds were coarse upon auscultation. Since the patient was intubated settings were as
followed: SIMV, FiO2 of 40%, PEEP of 7, tidal volume of 450, and rate at 12. The patient was
in normal sinus rhythm. This patient could not receive anything by mouth, referred to as NPO,
therefore nutrition and/or medications was given through the percutaneous endoscopic
gastrostomy (PEG) tube. The patient had right arterial line and right Shiley. During my shift I
noticed an abnormal arterial blood pressure reading on the monitor. I knew there was a problem

CLINICAL EXEMPLAR

when the arterial blood pressure (ABP) was consistently reading 80s for the systolic pressure
with a mean arterial pressure (MAP) below 60. Also, when reviewing the patients ABP in EPIC I
determined that this was very abnormal for the patient since previous trends was within normal
range. I immediately told my preceptor that my patients ABP is consistently decreasing and from
recent trends noted in the Medical Record this was an abnormal finding for this patient. My
preceptor had me page the provider. When the provider called back a bolus order was placed.
There are things that could have potentially affected the patient if the ABP and MAP was
not corrected in a timely manner. An arterial blood pressure (ABP) is a major determinant of
regional flow and is frequently used as an alternate indicator of tissue perfusion (Magder, 2014).
For example, an abnormal ABP was a red flag for me and the first thought that comes to my
mind is lack of perfusion. This issue could result in critical organs not receiving essential
nutritions and oxygen needed when a MAP is consistently below 60 and ABP below its normal
range. If an intervention is not in place I am thinking the worst case scenario is the patient could
go into cardiac arrest which isnt good for either parties. Therefore, intervening was necessary to
prevent things from getting worse.
Conclusion
This was a great experience to assess my decision-making and critical thinking skills. I
feel that once the problem was identified I reassessed the patients blood pressure, made sure the
line was zeroed accordingly and in the phlebostatic axis position, and closely monitored the
arterial blood pressure. Within minutes I felt that an intervention was needed to correct the
patients arterial blood pressure. I feel that I was about to make the best decision based off of my
understanding of normal arterial blood pressure range. Then by assessing the patients trend

CLINICAL EXEMPLAR
while in the MICU was a significant factor that calling the provider for an order was necessary
since a standing order to correct this situation was not in place.

CLINICAL EXEMPLAR

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Reference

Magder, S. A. (2014). The highs and lows of blood pressure: toward meaningful clinical targets
in patients with shock. Critical Care Medicine, 42(5), 1241-1251 11p.
doi:10.1097/CCM.0000000000000324