Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar

Steven Martinez

University of South Florida

CLINICAL EXEMPLAR 2

Clinical Exemplar

Everyone gets into nursing for different reasons, but the commonality that most people

share is being able to care for sick individuals compassionately in their moments of poor health

and stressful situation. While going through my clinicals I face to face interactions with patients

helped solidify that I am on the right career for me in healthcare. A nursing exemplar is a story

that reflects on an event or events that were memorable and significant and paints the picture for

your clinical practice. Exemplars show how you made a difference for a patient based on your

practice and help to open new ways to provide care (Pachini, 2006). My exemplar reflects on an

interaction with a patient who needed severe medical education and needed to understand why

lifestyle changes are important with a new diagnosis.

The patient was admitted to an outside hospital on 10/13/18 for shortness of breath and

atrial fibrillation with rapid ventricular rate above 160 bpm. He was cardioverted twice and then

went home AMA. The next day he was having the same symptoms and his wife took him to

Tampa General this time and was cardioverted once but went back into afib. The patient had a

history of kidney cancer (left radical nephrectomy) and hypertension. The patient stated that, “I

am healthy and don’t need to ever go to the doctor” which would explain the short list medical

history. He also said he gets anxious easily and that work is the only thing that calms him down

(he is still working at age 75, but from his laptop).

I took care of this patient back to back shifts. His heart rate on the first shift was

extremely irregular jumping from the 30’s to the 110’s repeatedly. He was becoming more tired

as the day progressed as well, which I attributed to his heart working so hard from going

bradycardic to tachycardic and back again so rapidly. He was also waking up in the middle of

the night to urinate because of Lasix, which could contribute to him being tired as well. His
CLINICAL EXEMPLAR 3

amiodarone drip was increased to 0.5mcg/min after contacting the Coronary Care Unit (CCU)

team. Towards the end of the first shift his heart rate was becoming less sporadic. The patient

refused several medications claiming that they caused cancer or that he just didn’t need them.

The range of the patient’s heart rate began to narrow after contacting the CCU team. The

patient stated, “See I am doing better now. As soon as I get out of here I need to work on my

boat.” This is when I realized the patient needed education on his condition. I let the patient

know that his CHF condition could be contributing to his afib and that his high levels of stress

can exacerbate it. I told him about needing to take daily weights and having a reduced fluid and

sodium diet (I gave examples of food with low salt and told him any weight gain/loss of two

pounds in one day needs to be reported to his provider). I also stated that activity is going to

have to be advanced as tolerated. Start with short walks and then gradually increase activity.

Not long after the patient education I had to contact the CCU team again because of the wide

various heart rates again. What may have been happening is that once switched to oral

amiodarone he wasn’t receiving a similar dose while on a drip and needed a higher oral dose.

The situation had potential for a critical episode since the heart rate would get as low as the 30’s,

so to act proactively I placed AED pads on the patient preemptively in case we needed to

defibrillate him. The patient requested a foley to try and help him sleep at night, so I contacted

CCU to make sure it was indicated for him. He had apparently refused a foley the first time, so

this time I placed one after orders were put in.

Shortly after the amiodarone drip was discontinued the patient was switched to oral

amiodarone. The plan of care was to wait for his Primary Care Provider to return to the country

and perform an ablation. I noticed the heart rate irregular range began to widen again so I

contacted the CCU team again. His oral amiodarone was then changed from BID to TID. I
CLINICAL EXEMPLAR 4

knew I was making the right decision because contacting CCU and getting the order changed,

helped to eventually bring his heart into a sinus rhythm. One huge risk of returning a patient to a

normal rhythm from atrial fibrillation is stroke from a clot in the left atrium being sent to the

brain (Kirchhof et al., 2017). To reduce clot formation chances the patient was on apixaban, an

oral blood thinner. I also frequently assessed the patient’s neurological status to make sure there

were no signs of an on-setting stroke or clot being sent somewhere else.

At the end of my second shift the patient was maintaining sinus bradycardia with a heart

rate in the 50’s. Contacting the CCU team about the rebound irregular heart rate once switched

to oral amiodarone was the right call. The new order of 400mg P.O. amiodarone TID helped to

stabilize the heart rate. The insertion of the foley catheter should also help the patient get much

needed rest while being on Lasix too. The best thing I was able to accomplish this shift was give

patient education on congestive heart failure. The patient thought it was a condition that could

just be cured and didn’t need lifestyle changes. It took several hours to finally get understanding

through to the patient and I even found a brochure all about CHF that I let the patient and his

spouse have. The patient refusal of medications I could have dealt with better. He was getting

angry because he already said he didn’t want certain medications to other nurses. I should have

explained the importance more in-depth. For example, he kept refusing Colace, but had no

bowel movement for five days.

My key enlightenment while taking care of this patient was realizing that most people

that are not in the medical field do not have solid healthcare understandings. One of the hardest

things for me to do at first was trying to explain signs, symptoms, and a patient diagnosis at the

sixth-grade level so they truly understood what I was saying. It is extremely important that they

understand and having the patient teach back to me as the nurse helps to confirm if they do or do
CLINICAL EXEMPLAR 5

not understand the care they need. I will make it one of my top priorities to not only educate, but

make sure the patient can demonstrate that they understand the education to prevent hospital

readmissions as much as possible. Taking the holistic approach and treating the patient as

another human being rather than just focusing on what is wrong with them sets apart the great

nurses.
CLINICAL EXEMPLAR 6

References

Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., . . . Vardas, P. (2017).

2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in

Collaboration With EACTS. Revista Española De Cardiología (English Edition), 70(1),

50. doi:10.1016/j.rec.2016.11.033

Pachini, C. M. (2006). Writing Exemplars. Retrieved November 30, 2018, from

https://www.med.umich.edu/nursing-PDE/framework/docs/writingExemplars.pdf