Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar

Marline Faustin

University of South Florida

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CLINICAL EXEMPLAR

Reflective Journaling

Name: Marline Faustin Date: June 9, 2017

Noticing

Subjective and objective data

o This patient was a 25-year-old, who presented to the emergency department

following a traumatic motor vehicle accident. The patient was brought to the

hospital via helicopter. The patient was 38 weeks (G1P0) pregnant and had to

undergo an emergency C-section. All vital signs were relatively stable besides a

heart rate(HR) of 120 bpm. She complained of severe left hip pain and had a GCS

of 15 upon arrival. The patient sustained a dislocated left hip fracture and had a

placental abruption causing her to lose her baby. A left hip reduction was

performed, and her uterus was removed to stop the bleeding. The patient was not

aware of what happened upon arriving at the surgical trauma intensive care unit

(STICU), which was the floor that this patient was presented to me. The patient

was on a ventilator, tube feeds and had a two balloon Foley in place. On the

morning I had this patient orders were placed to extubate. After all safety checks

were completed, and the patient was successfully extubated. Most of the patients

labs were within normal range except her sodium was 150, slightly elevated, and

her vital signs were normal except HR of 140. The plans for that day were to

inform the patient about her condition, stabilize HR, monitor sodium and monitor

closely for any complications.

How did you know there was a problem? Abnormal patient presentation or your

gut feeling?

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CLINICAL EXEMPLAR
o For this clinical situation, the patient started improving after being extubated.

Tube feeds were discontinued patient complained of being thirsty shortly after

and her diet was advanced from NPO to clear liquids. I concluded that the patient

was thirsty because her sodium was elevated, she might have been slightly

dehydrated. The only thing that kept this patient on STICU was her elevated HR.

The patient did not show any other signs of complications.

Interpreting

For this case, my preceptor and I worked closely together on it. The OBGYN

team talked to the family and discussed a time to explain everything to the

patient. I was given directions from my preceptor to not say anything

regarding the loss of her baby to the patient. TGH trauma, USF OBGYN

team, and Ortho trauma were following this case. When the time came to

explain what happened to the baby the chaplain team came to help console

the patient and provide support along with the patients family. On a separate

occasion, the OBGYN team came to explain to the patient that they had to

also remove her uterus. The patient was truly devastated and exhibited signs

of sadness, disbelief, and guilt. My preceptor and I suggested that neuro

psych be consulted so that the patient can be further evaluated. Besides the

emotional issues present in this case the patient also experienced generalized

pain. My preceptor administered 0.5mg of Dilaudid to the patient for the

pain, and she had a mild reaction to it, and the family requested to flag this

medication as an allergy. She was then placed on a new pain medication,

Percocet. We requested orders be placed to administered Xanax to the

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patient after the bad news was given to her about the situation because she

started to feel anxious and SOB. Although, her oxygen saturation was in

normal range.

Responding

Should I do something now or wait and watch? How will I know if I am making the

best decision? What interventions can I delegate to other members of the healthcare

team? Include evidence-based practice (peer reviewed) here to justify why you

might make one decision over another.

o For this case, I monitored the patient closely for any signs of bleeding, infection

and fluid retention by consistently monitoring her VS, measuring her urine and

assessing her skin every two hours when we repositioned her. On multiple

occasions, my preceptor put in requests for the lift team to help better reposition

her, and I made sure that while they were repositioning her that they paid

attention to her central line and Foley catheter. I also understood that not only was

this patient was impaired physically but also affected psychologically by the loss

of her unborn child. Prenatal loss has a big psychological impact on parents that

causes complicated grief reactions that put a high risk on psychological and

physical well-being (Kersting &Wagner 2012). After reviewing this article,

making the decision to have this patient evaluated with the Neuropsyc team was

the right choice to make. This was a big life changing event for this patient, and

her family and studies show many parents that do not get the proper treatment to

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cope with the loss exhibit depression, anxiety, post-traumatic stress, and sleep

disorders (Kersting &Wagner 2012).

Reflecting

Did I make the right decision?Did I achieve the desired outcome?What did I do

really well? What could I have done better?

o This case was a touching case for me. I truly empathized with the patient. My

preceptor and I did everything as a nurse, we could have done to make her

comfortable. I believe monitoring her closely for any signs of complications was

the appropriate thing to do. Waiting for the right time to tell her what happened

was also a good decision made by the medical team. By the end of the day we

were still working our way towards the desired outcome of decreasing her HR,

but unfortunately, it was still elevated. Medication was not given for the patient's

HR to go down because she had a normal blood pressure and no symptoms were

present. I feel like I provided good patient care by assessing her needs, properly

removing her Foley, monitoring her VS and asking her permission to assist in her

care. I believe there is always room for improvement and if there were one thing I

could do better, it would be knowing exactly what to say to provide therapeutic

communication after the bad news was given to her about her baby.

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Resources

Kersting, A., Wagner B. (2012). Complicated grief after perinatal loss. Dialogues Clinical

Neuroscience. 14(2) Retrieved from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384447/

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