Clinical Exemplar

Catelyn Suttmiller

University of South Florida

Clinical Exemplar

A clinical exemplar is defined as a narrative that is brief, focused, and illustrates or

discusses specific content (Winkelman, Kelley, & Savrin, 2012). This is a moral distress clinical

exemplar discussing a young female patient that received a left modified radical mastectomy,

who had a history of intravenous (IV) drug abuse. This clinical experience taught me about poor

pain control due to tolerance, as well as poor planning.


A 34 year old female patient had a left modified radical mastectomy performed. Her

surgery was delayed for over a month because she was using her port to inject heroin; which left

her with endocarditis and an infected port. She was then hospitalized for endocarditis and sepsis.

When she was approved for surgery, she had a new port placed and the physician

consulted with pain management prior to her procedure. The pain management team leaves the

hospital at 1700 and she was not admitted onto the floor until 1800. Proper pain medications

were not ordered prior to her admission to the floor because they were expecting the pain team to

take over her analgesic regimen. She was extremely drowsy when she first arrived to the floor.

During her initial assessment, she began to scream for her “mommy” and tried to run out of bed

only being two hours out of surgery. Once we got some pain medication on board the patient

stayed combative and reported having no pain relief. Security was called once she tried to hit a

nursing assistant who was trying to calm her down. She kept frantically trying to run out of bed

and then would heal over in pain. She threw her bedside table at her 21 year old daughter and

started stating that she wished her surgery did not go well and that she did not wake up. The

patient was screaming so loud the patients in the rooms down the hall claimed they could not

sleep nor relax with the disturbance she was causing. On multiple occasions the patient was upset

because she did not realize that she would be in that much pain from the mastectomy.


This patient should have had a psych evaluation prior to being approved for surgery, as

well as had the pain consultation before her surgery. When the surgeon realized that the

interdisciplinary teams she consulted were no longer in the building, the patient’s surgery should

not have been performed. With this patient’s history of drug and alcohol abuse there should have

been extra steps taken to set this patient up for a successful recovery. She could have benefitted

from therapy prior to her surgery and education to ensure she understood that she would have

some pain after the surgery. Pain can be controlled, but typically a patient will not get down to a

pain level of zero the day of surgery. Mastectomy patients have a high occurrence of chronic pain

following this procedure (Humble, Dalton, & Li, 2014).


Humble, S., Dalton, A., & Li, L. (2014). A systematic review of therapeutic interventions to

reduce acute and chronic post-surgical pain after amputation, thoracotomy or

mastectomy. European Journal of Pain, 19(4), 451-465. doi:10.1002/ejp.567

Winkelman, C., Kelley, C., & Savrin, C. (2012). Case histories in the education of

advanced practice nurses. Critical Care Nurse, 32(4), e1-e17. doi: 10.4037/ccn20123