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Jessica Panasewicz
My preceptorship in the Coronary Care Intensive Care Unit at Tampa General Hospital
was truly a wonderful learning experience. There were some days that were slow and the patients
were generally stable, and others that were so busy and hectic I could barely keep up. Pacini
(2013) describes a clinical exemplar as a story about your clinical practice that conveys
preceptorship in the ICU. It describes how I handled it and what I learned from it.
Noticing
A 71 year-old female presented to the hospital for a scheduled breast implant removal.
She had gotten into a MVA two months prior, where an MRI revealed a ruptured implant. During
the procedure, she began to have ST elevation and went into cardiac arrest. After 6 minutes of
ACLS, ROSC was achieved. An EKG was performed and after a STEMI was noted the patient
was immediately taken to the cath lab. Her right coronary artery was stented and she came up to
us at CCU. Within 45 minutes of her arrival, the NP that was evaluating her noticed significant
ST elevation on the monitor. Once another EKG was performed, which revealed greater ST
elevation than before, the patient was rushed back down to the cath lab. Her stent had clotted, so
the patient was put on an intra-arterial balloon pump via her right femoral artery and Integrilin
was started. The patient came back to us and was determined to be 1:1 monitoring with q 15 min
vitals. The patient was intubated and on a vent. She had two JP drains, one from each breast,
secured with an abdominal binder. The patient required heparin, propofol, and pressers.
CLINICAL EXEMPLAR 3
In this situation, it was clear there was a problem. The patient had presented in good
health to the OR, but by the time she was in the CCU, she was clearly critical. Looking back at
her history, the patient seemed to be very non-compliant. After 60 years of smoking, there was
note of a suspected lung cancer in 2005 but the patient stated she didnt want to know about it.
Otherwise, the patient had no significant cardiac history. Once the patient initially came up to
the CCU there was a lot going on. The NP was showing me and two other medical students how
she was putting in an arterial line in the femoral artery. After the line was in, the NP felt
something wasnt right because of how the ST elevation looked now compared to in the cath lab
initally. Because I was not with the patient initially to see the first EKG, I wasnt aware of the
difference, but knew from the NPs assessment that this wasnt good.
Interpreting
The patient was being closely monitored by Gulf to Bay, cardiology, plastic surgery,
vascular surgery, and CT surgery. Upon taking a temperature, the patient was reading anywhere
between 95-96 degrees F and her skin felt ice cold, so I placed a bear hugger on the patient and
inserted a temp-probe foley. When I was emptying the patients drains, she was putting out a
significant amount of sanguineous drainage at about 100 ml/hr in both drains. When plastic
surgery came by, I notified them of the patients excessive drainage. I had a feeling she would
need some blood transfusions in the near future. It seemed like the patient was bleeding from her
surgery, but there was a higher amount than what is expected, which signaled to me that the
patient was in really critical condition and her body was fighting hard to keep her alive.
Responding
The patient needed close supervision and many interventions. Every time the providers
came by, I made sure to give them a status update. YeongHo et al. (2017) states that timely
CLINICAL EXEMPLAR 4
percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are
crucial in the management of a STEMI patient. The PCI was performed initially upon arrest
which was important, but because it clotted off shortly after, became concerning. I had never
seen the doctors so frustrated and confused about what to do next. The patient was also on
Integrilin and Heparin, which was necessary to prevent clot formation, but placed the patient at a
higher risk for bleeding when she was already bleeding significantly from her surgery. RT was
watching the patients vent settings and ensuring they were followed-up accordingly. At this
point, my nurse and I were monitoring the patients status closely and following the orders from
the providers. I felt there was nothing else that could be done until further progression of the
Reflecting
For this patient, I feel the right decisions were made by the care team in the moment. My
nurse and I were doing everything we needed to do in a timely manner and watching the vitals q
15 minutes. We were drawing blood frequently to assess hemoglobin and blood gases, and caring
out the necessary interventions. With the patient being so cold, it was hard to get a temperature
reading so the bear hugger and temp-probe Foley were a must. I feel the desired outcomes were
achieved as best as possible but undoubtedly this patient was crashing. I feel I identified risk
factors for this patient really well, such as bleeding precautions, changes in vitals (what to look
for in hemorrhagic or cardiogenic shock), and temperature management. I also noticed this
patients urinary output was dropping and suspected the kidneys were shutting down, which
turned out that the patient was later identified to have AKI. I feel what I could have done better
would have been to have a better understanding of some of the interventions that were being
done to her, such as the inter-aortic balloon pump, because it would have helped me to
CLINICAL EXEMPLAR 5
understand a little bit more about what to look for and how to best care for this patient. Although
I wanted to learn more in the moment, there was so much going on so I had my nurse explain to
me what she could and did my research after. Overall, I think this patient taught me a lot about
critical care and how quickly a stable patient can deteriorate. I also learned that having extensive
background knowledge before receiving a very critical patient like this is imperative to take the
best care of the patient and I will better prepare for this in the future.
Conclusion
Its no doubt that days in the ICU are unpredictable. My clinical exemplar shows just
how challenging these days can be. Although you cant plan for the challenges you may face on
the job, you can definitely be prepared for them. This day in the ICU taught me so much about
the knowledge you need to have to work in the ICU and just how vital teamwork is in the
process. It is a day that I will take with me to my future endeavors as a new registered nurse.
CLINICAL EXEMPLAR 6
References
PDE/framework/docs/writingExemplars.pdf
YeongHo, C., Yu Jin, L., Sang Do, S., Kyoung Jun, S., KyungWon, L., Eui Jung, L., & ... Ro, Y.