Running head: CLINICAL EXEMPLAR Buchholtz 1

Clinical Exemplar
Deanne Buchholtz
University of South Florida
NUR 4948L
7/17/14














CLINICAL EXEMPLAR Buchholtz 2
The Mountain State Health Alliance (2014) defines a clinical exemplar as, A first person
story written by a nurse that describes a specific clinical event or situation. This tool provides
insight into a nurses current practice, offering other health care professionals who may read it a
mode by which to examine certain dilemmas in the clinical setting and how they themselves
might handle given situations. This narrative not only allows for the nurse to reflect on things he
or she may be succeeding in, but also may illuminate areas for improvement. The clinical
exemplar allows for a first-person view of the nurses current routine, skills and problem solving
abilities, and also provides an avenue for self-reflection. The subsequent narrative outlines one of
my own experiences as a student nurse on a surgical telemetry floor.
One shift this past semester I had the pleasure of being the nurse of a very sweet elderly
patient for the second time. The 77 year-old female had been admitted on 6/7 with a diagnosis of
CHF and NSTEMI. She had a history of DM II and afib. When I went in to greet her and
perform her morning assessment, I noticed she looked dramatically different from the first time I
had seen her. Her face was very puffy, and as she laid on her left side, her left eye swelled shut. I
palpated her face, hands, and abdomen, noting edema. She told me that she felt very bloated and
uncomfortable. The patient had been NPO since midnight in order to prepare her for a CT of the
abdomen. She had not been stooling for a while and staff were trying to rule out a bowel
obstruction. She had been on 0.9% NS since being admitted for hydration, and was being given
stool softeners and laxatives periodically. However, my gut was telling me something was going
on besides the lack of stooling.
I needed to first confer with my nurse, in case there were any orders or updates I had
missed. She directed me to check the morning labs and vitals, which had just come in. Vitals
CLINICAL EXEMPLAR Buchholtz 3
seemed normal. The patient was afebrile, with good blood pressure and respirations. Her last
blood glucose had been 76, so this was no cause for concern at the time. I scanned the labs and
noticed two things: that her Na level was low at 122 and trending down over the past three days,
while her K level was high at 5.3 and trending up. Since these values seemed severe, I pointed
my findings out to the nurse immediately. She and I thought briefly, then it dawned on me that
her NS fluid had also seemed to be running at a high rate of 75 ml/hr. Could my patient be
retaining fluid? After all, she is a CHF patient. The facts were lining up.
Both my nurse and I agreed this was not the right time to take a wait-and-see approach. I
She had me call the attending physician and give report on my patients change in status, that she
was edematous and at risk for fluid volume overload. According to Za Zhi, body fluid needs to
be maintained at an adequate level to ensure hemodynamic stability and tissue perfusion (2009).
The doctor (to my surprise, actually) agreed with me that the NS infusion needed to be
discontinued and that the patient needed diuretics to flush out the excess fluid. He asked to be
given a status update in four hours. I followed his orders and went into her room to stop the
infusion, while my nurse documented the phone call and new orders. I also requested the techs
on the floor to keep an eye on my patient also, in case I got caught up in other duties.
I am confident I made the right decision, both to bring my patients condition to the
attention of the nurse and the doctor, and also to recommend the discontinuation of the NS
infusion. My patient was just not in the state of health to handle the rate of fluid being pumped
into her body. Furthermore, stopping the infusion and administering diuretics helped us achieve
the desired outcome. My patient looked and felt significantly better by the afternoon rounds. Stat
labs had also been ordered earlier, and I noticed her Na and K levels were trending back toward
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therapeutic ranges. What I could have done better is recognize the need for my patient to be on
consistent diuretics while I examined her chart in the morning. Since this patient has CHF, there
are certain protocols to follow. I still need practice with my critical thinking.















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References
Mountain State Health Alliance. (2014). Clinical Exemplars. Retrieved July 14, 2014, from
http://www.msha.com/Uploads /files/Nursing /BESTClinicalExemplars.pdf

Za Zhi, Hu Li (2009). Evidenced-based practice of fluid restriction in patients with heart failure.
US National Library of Medicine. Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/19760574