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Running head: CLINICAL EXEMPLAR: REFLECTIVE JOURNALING 1

Clinical Exemplar

Kristina L. Nealy

Univeristy of South Florida College of Nursing


CLINICAL EXEMPLAR: REFLECTIVE JOURNALING 2

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
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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.
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References

Elsamadicy, A., Wang, T., Back, A., Lydon, E., Reddy, G., Karikari, I. (2017). Post-operative

delirium is an independent predictor of 30-day hospital readmission after spine surgery in

the elderly (65 years old): A study of 453 consecutive elderly spine surgery patients.

Journal of Clinical Neuroscience, 16. doi: 10.1016/j.jocn.2017.02.040