CLINICAL EXEMPLAR 1

Clinical Exemplar

Natalie C. Sorensen

College of Nursing, University of South Florida

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Clinical Exemplar

Patient Situation

The patient I am going to discuss presented to the hospital with complaints of intractable

nausea, vomiting, and diarrhea that had been occurring for two to three weeks. The patient also

presented as weak, hypotensive, and with a decreased urine output. The patient’s creatinine on

admission was 4.2 and her BUN was 114. It was determined that this patient was in acute renal

failure. I was caring for this patient in the ICU three days after her admission.

Problem

My preceptor and I identified a problem when we were talking with this patient and her

daughter about the patient’s medications during morning medication administration. We were

gathering information regarding the patient’s home medications which included her

understanding of the medications, how long she had been taking these medications, how she had

been taking these medications, etc. The patient’s past medical history included pulmonary

hypertension, and the patient and her daughter explained that the patient had been taking

sildenafil and macitentan for the pulmonary hypertension. They explained that recently, on

January 5th, the patient’s doctor had added selexipag to her regimen for pulmonary hypertension.

The patient reported that the intractable nausea, vomiting, and diarrhea had started after she

began to take the selexipag, and she thought that the selexipag was causing these gastrointestinal

symptoms. Hearing this, my preceptor and I realized there was a problem in that the patient’s

medical team might have been missing the root cause of this patient’s acute renal failure:

dehydration from prolonged vomiting and diarrhea.

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Action

Because this information that the patient and her daughter provided could explain the

cause of this patient’s acute renal failure, it is important to share this information with the

patient’s medical team. This information affects the patient’s treatment plan in terms of

medication administration as well because the patient is not absorbing medications fully (or at

all) nor maintaining proper hydration when she is constantly vomiting and having diarrhea. This

means that careful consideration needs to be taken when coming up with a medication

administration plan. This situation was not critical but it was time sensitive in the sense that we

needed to contact the medical team within a few hours. My preceptor and I decided that the best

course of action would be to give all of the morning medications exempt for the selexipag, and

then to discuss the situation with the medical team in the next few hours and recommend to give

selexipag with some ondansetron at noon. We wanted to separate the selexipag from the other

medications our patient was receiving in terms of time of administration in hopes of determining

if it was the selexipag that was causing the vomiting and diarrhea. This rescheduling of the

medication administration time was also to give the other medications time to be absorbed by the

patient prior to the administration of the selexipag in case the selexipag caused the patient to

vomit. We wanted to give ondansetron in combination with the selexipag in order to provide

some nausea relief and hopefully prevent the patient from vomiting. The medical team came by

for morning rounds about an hour after we administered our patient’s morning medications, and

we relayed to them what our patient had told us and discussed giving the selexipag at noon with

the ondansetron. We also made sure to let the medical team know that the patient had not been

getting all of her medications during the previous shifts and had been experiencing nausea and

vomiting. The team was unaware of this. The team agreed on holding the selexipag until noon
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and giving it with ondansetron. I believe we made the right decision because we provided the

medical team with important information that could help them better understand how to treat our

patient. We also advocated for our patient’s comfort by requesting ondansetron. The outcome of

our decision making was positive in that our patient experienced no nausea after the morning

medications and little nausea after the selexipag and ondansetron. However, after the selexipag,

our patient did experience two episodes of diarrhea. Therefore, further advocacy for our patient

will be required, likely involving requesting a new medication to replace the selexipag and an

antidiarrheal in the meantime. I think holding the selexipag in order to discuss with the medical

team about the situation was a good decision because this promoted the comfort of my patient as

well as the health of my patient by allowing the other medications to be absorbed first. I think the

only thing we could have done better in this situation was to contact the medical team before

they came to make their morning rounds. This situation will impact my future care as I will pay

close attention to my patients’ commentaries on medications as sometimes medications have a

huge impact on diagnosing. The medication reconciliation process is key for this as knowing

what medications someone is on and having them be aware of the medications they are on is

huge (Almanasreh et al. 2016). If a patient is does not make the staff aware of their medications,

there can be confusion and also dangerous consequences (Redmond et al, 2018).
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References

Almanasreh, E., Moles, R., & Chen, T. F. (2016). The medication reconciliation process and

classification of discrepancies: a systematic review. British journal of clinical

pharmacology, 82(3), 645–658. https://doi-org.ezproxy.lib.usf.edu/10.1111/bcp.13017

Redmond, P., Grimes, T. C., McDonnell, R., Boland, F., Hughes, C., & Fahey, T. (2018). Impact

of medication reconciliation for improving transitions of care. The Cochrane database of

systematic reviews, 8(8), CD010791. https://doi-

org.ezproxy.lib.usf.edu/10.1002/14651858.CD010791.pub2