Clinical Exemplar

Clinical Exemplar: Learning to Prioritize Patient Care for a Patient with

Multiple disease processes

Preceptorship NUR 4948L

Morghan Walrich 

University of South Florida

         As I near the end of my last semester as an undergrad and nursing student, I enjoy reflecting on some of the more memorable and recent experiences during my preceptorship at All Children’s Hospital. I am so fortunate to have done my clinical hours in the NICU (neonatal intensive care unit), and I feel more confident in the field of pediatric/neonatal medicine now that I have been acclimated to a nurse’s role in a pediatric hospital. I spent three and a half months in the NICU with two different precepting nurses who were such an inspiration to me.  I was able to observe their excellent assessment skills, knowledge, compassion, professionalism, and high level of patient care.  Every clinical day I would also write a journal based on my experience with the patients I was assigned to, which helped build my critical thinking and decision-making skills.  The theory behind clinical exemplars such as reflective journaling or narratives such as this one, is that we as nurses learn from experience.  According to an article from the Newborn and Infant Nursing Review Journal, “the ability to reflect is an important component for the development of competency” (Altimier &Lasater, 2014).  Clinical exemplars involve thinking about the thoughts that occur as a situation or event is unfolding. Reflection can also occur following the event (Altimier & Lasater, 2014).  Writing about clinical cases enables us as nurses to look at actions, thoughts, and feelings, which is a means of learning from practice as stated in the article.  The following story was one of a patient I was assigned to on a day in the NICU that helped me understand various aspects of managing a critical and unstable infant. 

        The second day of clinical, I came in to a two patient assignment, which was typical for the Admissions pod where the more premature and critical babies were. While receiving report from the night shift nurse, I noticed the baby laying in the open isolette had a Silo set up which held part of her intestines in a suspended vacuum bag over her body.  According to the patient’s medical history, it was confirmed that she was born with gastroischesis, a condition in which the baby’s colon is displaced outside the abdomen. In this case, the intestines were protruding on the right side of the umbilicus.  The baby was delivered via cesarean section at 37 weeks gestation one day prior at ACH.  Immediately before being transferred to the NICU, the patient’s physician performed a Silo procedure and enclosed the colon, which was held in suspension, with hopes of reduction within a week. The goal was to allow proper space for her lungs to expand and relieve pressure within the abdominal cavity. An echocardiogram also showed the patient had cardiomegaly, which caused compression of the lungs.  The patient was previous intubated due to increased work of breathing at birth (retractions, grunting, nasal flaring, etc.) The patient suffered from respiratory distress syndrome (RDS). When I came on to the floor that day, the patient was extubated and on room air.  She was also sedated on a fentanyl drip.  The night shift nurse mentioned that the GI specialist was planning surgery to reduce the Silo and close the baby’s abdomen the following day.  The patient would have to be reintubated prior to surgery.  

  After report was finished, my preceptor and I began our day with a full hands-on assessment of the infant to obtain our baseline information.  Her blood pressure was 65/42, pulse 140 bpm, respirations 38, temperature 36.8 Celcius, oxygen saturation 99%, and pain 0.  Upon auscultation I heard good heart sounds, however the infant was slightly stridorous, which presented as an inspiratory wheeze.  Her lungs were clear and equal which made me think maybe the problem was more in the airway. I did not note any retractions on my first assessment, because the baby did not seem to be having trouble breathing.  

Soon after morning assessment, the GI specialist came to reduce the Silo back into the patient’s abdomen to see how she did with the added abdominal pressure.  A few hours later, my preceptor and I could audibly hear the patient wheezing loudly, and grunting, both signs of increased work of breathing and her condition was worsening.  We performed another assessment, confirming the stridor and also noticed the patient was developing substernal retractions.  My preceptor spoke with the patient’s physician, who ended up coming to assess the baby at bedside.  Based on the patient’s worsening respiratory status, the practitioner decided to reintubate.  When she did, she found that the baby’s trachea was damaged and swollen, making intubation very difficult.  After two attempts, she was able to confirm good tube placement.  The practitioner let the GI specialist know that the patient was having difficulty breathing, and that she too believed it was mainly an airway issue.  The specialist came by and decided the patient should not have surgery the next day as planned because he wanted her to be more stable and able to maintain adequate lung expansion with the reduction before closing her abdomen.  More observation was necessary.  

After intubation, the patient seemed less restless and the retractions seemed to subside within a hour, showing that her respiratory status was improving as well.  Because the Silo was reduced, my preceptor and I kept a close eye on the patient’s blood pressure, which remained stable.  Between having cardiomegaly and a newly reduced Silo, we were concerned that her pressure would be elevated and her lungs would not have enough room to expand.  I learned so much that day in regards to monitoring and assessment, as well as the importance of close communication with practitioners and surgeons.  I was able to recognize that there was a definite and progressive respiratory problem, and that the patient was most likely extubated too soon, left with a very edematous and narrowing airway.  The goal was reached, and the patient was oxygenating well with a more patent airway by the end of the shift.  

References

Altimier, L., Lasater, K. (2014). Utilizing reflective practice to obtain competency in neonatal 

nursing. Newborn and Infant Nursing Reviews, 14(1), 34-38. 

doi: 10.1053/j.nainr.2013.12.008