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Clinical Exemplar
Kristina L. Nealy
Clinical Exemplar
Noticing
An87yearoldmalewasadmittedalittleovertwomonthsagoforbacksurgery.Duringhis
hospitalstaythepatientdevelopedabowelobstructionandendeduphavingtohaveabowel
resectionandmanyothersurgeriesthereafter.Thepatientisverysickandhishospitalstayhas
hadmanyupsanddowns.Aweekbeforethisshift,rapidresponsewascalledforthepatient.
OnthisdaywhenIcamein,thepatientappearedlethargic,wasfebrile,weak,hypotensive,
hasveryfragileskin,astageIIIpressureulceronhiscoccyx,hematuria,painof8/10,burning
withurination,occasionalconfusion,anddrowsiness.Also,anabnormalnewfindingwasthat
thepatientspeniswasturningblack/purple.
Ihadthepatientthedaybefore(andoneortwotimesinthepast)andheseemedtobedoing
muchbetterandinmuchbetterspiritsthanhehadbeeninawhile.WhenIcameinforthisshift,
thepatientshealthhadapparentlydeclinedovernightandIhadagutfeelingthatsomethingjust
wasntright.
Interpreting
MynurseandIdecidedthatthepatientsattendingphysicianshouldbenotifiedaboutthe
patientsconditionandweshouldrecommendorrequestanorderforlabworkandaurinalysis.
Withhowsickthepatientalreadyis,howlonghehasbeeninthehospitalandgiventhe
circumstancesourfirstthoughtwasinfection.Giventhepatientscondition,thiscouldbea
criticalsituationdependingonwhatcouldbemanifesting.
Responding
CLINICAL EXEMPLAR: REFLECTIVE JOURNALING 3
Ourthoughtwastocontactthedoctorassoonaspossiblesoheknowswhatisgoingon.
Aswewereleavingthepatientsroom,hisphysicianconvenientlycameinatthattimesowe
wereabletostophimafterheleftthepatientsroomtodiscussthepatientscondition.The
Doctoragreedwithourrecommendationsandgaveusverbalorders.AccordingtoastudythatI
found,patientsovertheageof65whohadspinesurgeryareoftenreadmittedwithinthirtydays
oftheirsurgeryduetodiagnosesrelatedtothedelirium.Thispatientwasnotdischargedbutheis
stillwithinthethirtydayrangetodevelopasecondarydiagnosis.Itisimportantinthissituation
tokeepacloseeyeonthepatientanddothoroughassessmentsasalways.Ialwayswanttomake
thedecisionthatprovidesthebestoutcomeandsafetyforthepatient.Figuringoutwhatiswrong
withthepatientsoonerthanlatermayimprovetheoutcome.
Reflecting
IthinkthatIhandledthesituationwell.Thepatientandhisdaughterbothhadmany
concernsaboutthesamethingswewereconcernedaboutandwelistenedtothemvoicetheir
concerns.Thispatientwasveryillandwithhisvitalsignsbeingunstableandhishistoryjust
withinthepastmonthortwoitwasimportanttoactpromptly.Thepatientdidindeedhavean
infectionandhewasstartedonanotherroundofantibiotics.Wedidachievethedesiredoutcome
asthephysicianwasnotifiedasap,wegottheanswersweneededandthepatientwasOK.
CLINICAL EXEMPLAR: REFLECTIVE JOURNALING 4
References
Elsamadicy, A., Wang, T., Back, A., Lydon, E., Reddy, G., Karikari, I. (2017). Post-operative
the elderly (65 years old): A study of 453 consecutive elderly spine surgery patients.