1

“Anything else?” – When You are Your Patient’s Voice

Hannah Lai

University of South Florida

 2

Clinical Exemplar

Clinical exemplars are narrative reflections that have long been used in nursing practice

as anecdotal stories that capture the essence of nursing, showcase our practice in our profession,

and recognize clinical nursing excellence (Harvey & Tveit, 1994). In the following clinical

exemplar, I reflect on a challenging situation I faced as a nursing student where I advocated for

my patient by voicing my concerns to the provider.

“Anything else?” – When You are Your Patient’s Voice

On the morning of 6/28, I arrived at the Intensive Care Unit (ICU) for my 12th

preceptorship shift. I was in my final semester of nursing school and looking forward to my new

assignment for the day. My patient was a 37-year-old female that presented to the emergency

department five days ago after collapsing on her husband. She was dyspneic with severe lactic

acidosis upon presentation, so she was promptly intubated and admitted to ICU. When I assessed

her that morning, she was still being mechanically ventilated at 40% FiO2, but her lung sounds

were clear with minimal secretions. She was being titrated on propofol, fentanyl and Levophed

drips and responded to pain while on sedation. She also had 0.45% NaCl with 20mEq/L KCl

running at 100ml/hr through a right arm PICC. She was receiving small bore tube continuous

feedings of Vital High Protein at 30ml/hr with present bowel sounds. She was on oral and

intravenous antibiotics for positive C. difficile infection, and had frequent, large amounts of

liquid, brown stool throughout the day. Although she had a Foley catheter in place, there was a

low amount of urine output with brown sediment noted throughout the day, due to the presence

of a colovesical fistula. She had generalized anasarca, and her skin was not intact; she had a large
 3

stage 4 pressure ulcer on her coccyx with gauze packing, and several weeping wounds on her

abdomen, bilateral hips and thighs.

At 0900, my nurse and I performed a Passive Leg Raise (PLR) test to assess my patient’s

cardiac output and stroke volume index (ΔSVI). We notified the provider of my patient’s ΔSVI

of 13.2%. A ΔSVI of 10% or more is indicative that additional intravenous fluid administration

would significantly increase cardiac output and perfusion, so the provider ordered 1 Liter LRS

bolus (Cheetah Medical, 2018). We attempted a sedation vacation at 1025, but her repeat Arterial

Blood Gas (ABG) still showed severe metabolic acidosis. We communicated this to the provider,

so he ordered us to resume sedation and give her D5W with 3 ampules of sodium bicarbonate at

100ml/hr instead of the 0.45% NaCl with KCl. At 1700, we repeated the PLR test, which showed

an increase ΔSVI of 16.9%. We relayed this information to the night nurse during handoff report

with provider orders to repeat the 1 Liter LRS bolus overnight.

Upon arrival to the unit on 6/29 morning, my nurse and I were preparing to receive

morning handoff report when we noticed that the patient’s monitor displayed SpO2 at 87%. We

asked if she had been desaturating overnight, to which the night nurse responded that she had

not. We immediately gowned up and entered the room to assess the patient: I listened to her

lungs and appreciated coarse crackles and rhonchi throughout all her lung fields. I instantly knew

something was wrong; her lungs sounded much worse compared to the previous day and she had

thick oral secretions pooling at the back of her throat and in her endotracheal tube. We quickly

provided in-line suctioning of her endotracheal tube and oral suctioning.

We learned that the night nurse had forgotten to draw labs in the morning as ordered. My

nurse ordered a stat chest radiograph (CXR) per standing protocol for change in patient condition

and sent off morning labs. The night nurse admitted he gave the 1 Liter LRS bolus overnight as
 4

instructed, but never repeated the PLR test to recheck the ΔSVI. Although the night nurse

reported only one bowel movement overnight with normal urine output, from 0700 to 0900 the

patient did not produce any urine but had a large amount of liquid stool. We rechecked the PLR

test with a result of ΔSVI of 20.7%. CXR results came back and showed worsening retrocardiac

opacity. Differentials included volume loss, pleural effusion, edema vs. infection. The basic

metabolic panel (BMP) results showed an improved CO2 from 15 to 21 mEq/L; however, Na+

had elevated from 143 to 146 mEq/L, and K+ dropped from 3.8 to 3.2 mEq/L. BUN continued to

elevate from 49 to 52 mg/dL and Creatinine remained the same at 1.580.

As this patient was my primary assignment, my nurse gave me the responsibility of

leading the decision-making process. I felt the urgency to notify the provider concerning my

patient’s change in respiratory status including the diagnostic results of the CXR, BMP and PLR.

As interdisciplinary rounds were about to begin, my nurse told me I was in charge of notifying

the critical care pulmonologist intensivist, respiratory therapist (RT), charge nurse and the rest of

our healthcare team concerning our patient’s condition during rounds.

This was my first time presenting a patient during interdisciplinary rounds and I was

nervous and anxious. As I prepared to present, I could tell the intensivist was annoyed that a

student was giving rounds on the patient. I began with the proper SBAR format that we had

learned in school, but he impatiently interrupted with “I don’t have time for this! Just give me the

updates!” I quickly launched into a brief update on the patient desaturating in the morning, as

well as the worsening, coarse lung sounds heard and increased secretions in the endotracheal

tube. He interrupted again to question RT of ventilator settings and respiratory treatments, then

added new respiratory medications to the plan of care. I hesitantly continued with, “We also

ordered a stat CXR, which showed signs of worsening retrocardiac opacity”. I pulled up the
 5

results for him when he asked to see the report. After reviewing the report, the intensivist asked

what rate of propofol the patient was currently at and instructed us to “ease up on the sedation”.

He asked, “Anything else?” I promptly showed him my patient’s electronic medical record

(EMR) and stated that the patient also had abnormal BMP results. While he reviewed the results,

I reminded him that the patient had been placed on 3 amps of sodium bicarbonate at 100ml/hr the

previous day for a low CO2 that had since improved. Magnesium levels were not drawn that day,

so he instructed us to check the magnesium level and provided the following orders: “If

magnesium is less than 2 meq/L, give 1 gram or if it is less than 1.5 meq/L, give 2 grams. Also,

give KCl 20mEq PO 3 times every 4 hours, stop the sodium bicarbonate infusion and start the

patient on LRS 100ml/hr.” The intensivist gave these orders in quick succession and was about

to walk away when I hurriedly stated that the patient was previously on 0.45%NaCl with 20

mEq/L KCl at 100ml/hr and asked if we could restart that instead of the LRS. He said, “That’s

fine. Anything else?” I then mentioned, “Well yesterday the patient’s ΔSVI was 16.9% toward

end of shift and the night nurse gave 1 Liter LRS bolus per orders, but did not recheck the ΔSVI.

When the ΔSVI was rechecked in the morning, it was 20.7%”. He said, “Okay, well give a 2

Liter LRS bolus then”. Once again, he asked, “Anything else?” I said, “There was also no urine

output in the last two hours”. At that point, the intensivist exclaimed, “Of course, she’s

dehydrated! Anything else?” I hastily responded “No sir!” and he walked away abruptly.

Although I found the intensivist intimidating and his attitude off-putting, I was able to

bring up all my concerns with the provider and receive orders to modify plan of care. Under

these new orders, I was able to provide the necessary interventions to my patient and address her

fluid and electrolyte imbalance. Additionally, that afternoon we were able to wean her off

sedation and fully extubate her at 1525. Later that day, when the intensivist stopped by to see
 6

how the patient was doing post-extubation, he complimented me and said to me, “You know,

you did very well in rounds this morning, especially for a student…actually, better than some

nurses.” I found his comment to be extremely encouraging, especially since he had seemed

annoyed with me the whole time. Communication can be challenging, and learning to efficiently

and effectively communicate to different team members takes practice. However, this entire

situation solidified my determination to be my patient’s advocate despite how difficult

communicating with physicians may be. I realized that doctors place a significant amount of trust

in a nurse’s assessment and judgment; therefore, we have the duty to look out for our patients

and always notify providers when we believe something is wrong. This experience has taught me

to trust my instincts, never hesitate to speak up, and to be persistent in expressing my concerns.

Ultimately, when you are your patient’s voice, make sure your voice is heard until there isn’t

anything else.
 7

References

Cheetah Medical. (2018). Fluid management. Retrieved from https://www.cheetah-

medical.com/clinical-applications/fluid-responsive/

Harvey, C. V., & Tveit, L. C. (1994). Clinical exemplars to recognize excellence in nursing
practice. Orthop Nurs, 13(4), 45-53.