Clinical Exemplar 1

Clinical Exemplar: Managing an Unstable Patient

Addison Russo

College of Nursing, University of South Florida

Clinical Exemplar: Managing an Unstable Patient

Starting my preceptorship in the ICU was daunting and overwhelming. I was worried I

would not have the knowledge or skills to care for my patients. However, with the help of my

preceptor, I realized that I was more capable than I thought. The overall nursing process that I

had been using since the start of nursing school had not changed, what did change was the level

of detail and acuity of care that my patients now required. Perhaps the most stressful shift I have

had to date was my very first day of preceptorship. My nurse and I had an unstable patient who

was progressing to the refractory stage of sepsis, despite efforts to manage and treat the infection.

Noticing

The morning started out chaotic, with both a foley and restraints needing to be placed all

before 0800. At this point in time the patient was still alert and oriented. The foley needed to be

placed in order to monitor kidney function and urine output, as this is usually the first organ to

fail in septic shock. The restraints needed to be placed to prevent the patient from pulling out

their arterial line and removing their oxygen, despite repeated less restrictive interventions. This

patient was also on three pressors: vasopressin, norepinephrine, and phenylephrine. Even with

maximum doses of these three medications, their blood pressure was still low at around 90/50.

However, at this point in time their MAP was holding right around 65. Around noon things

began to take a turn for the worse. My nurse and I could tell by the steady decline in blood

pressure, decreased level of consciousness, and lack of urine output that this patient was

progressing to a more severe stage of septic shock. We knew we needed to contact the provider

to collaborate on how to best manage this patient’s condition.

Interpreting

This was a very critical situation as treatment of sepsis, especially as it progresses, needs

to be fast. My nurse and I contacted the physician, as well as the respiratory therapists, and

together determined that this patient’s overall perfusion was beginning to decline. Their

extremities were beginning to grow colder and colder with each assessment. Additionally, this

patient was becoming more acidotic as evidenced by the stat ABG that was ordered. Thus, it was

determined that further interventions needed to be put in place in order to better manage the

perfusion and oxygenation of this patient. This was now an extremely critical, time sensitive

case.

Responding

Due to the severity of this patient, it was imperative that my nurse and I, along with the

whole health care team act as soon as possible to give this patient the best possible chance at

survival. At this point, the patient was struggling to breathe effectively and unable to make

decisions on their own. We knew from the chart that this patient did not have a DNR or DNI in

place so the health care team acted in the best interest of the patient and intubated them.

Immediately following the intubation, the patient’s pressure dropped and pulses needed to be

assessed with a Doppler in order to be found. Since I had been using the Doppler all day when

assessing this patient, I quickly grabbed it and began listening for a radial pulse. It was weak, but

there. In order to further support the patient’s hemodynamics, a fourth vasopressor was ordered

by the doctor, epinephrine. Additionally, due to the acidotic state of the patient, sodium

bicarbonate was ordered. In a study conducted by Huang et al., it was found that sodium

bicarbonate administration to patients in an acidotic state due to sepsis could help reduce

mortality rates (2023).

At first the drop in pressure and hard to palpate pulses made me question if intubating

this patient was truly the best decision. However, since the patient was showing such severe

signs of decompensation it was the best decision given the current evidence to intube and

ventilate the patient to ensure that proper oxygenation was occurring. Furthermore, the ventilator

would ensure that the patient was effectively blowing off carbon dioxide which would help

decrease the acidotic state the patient was in, since carbon dioxide is an acid (Maccagnan et al.,

2021).

During the intubation process, a lot of health care workers were in the room and a lot was

going on. The physician intubated the patient after my preceptor administered the sedative and

paralytic medications. The charge nurse was documenting the times of medication administration

and intubation. It was my responsibility to check the pulses after intubation, using the Doppler,

and then place the OG tube after successful intubation. This is just one of many scenarios I have

been involved in where communication and team work is imperative to ensure the best care is

provided for the patient as many people and tasks are involved.

Reflecting

Overall, I believe that my nurse and I made the right decision to intervene quickly as

soon as we noticed that there was a lack of urine output, decreased blood pressure, and a

decreased level of consciousness in our patient. This was a situation where I used the ABC

prioritization framework to determine not only the severity of the case but also when to

intervene. Since blood pressure falls under circulation it was important that I contact additional

healthcare providers in order to maintain perfusion of vital organs in my patient.

It is hard to say, however, if the desired outcome was achieved as this patient still

continued to decline. By the end of the shift the patient was maxed out on all four vasopressors
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and their heart rate was around 150 beats per minute. Their blood pressure did improve to an

average of 100/70 and their MAP held at above 65 for the duration of my shift. The sodium

bicarbonate and mechanical ventilation did help improve their ABG slightly in the remaining

hours of my shift, but it was evident that this patient’s chances at survival were slim.

This is a day that will stick with me for the rest of my nursing career. I learned a lot this

day on how to manage an unstable, critical patient. I was proud of myself for realizing the early

signs of progression to later stages of shock and bringing it up to my nurse so together we could

contact additional healthcare professionals. Communication is so important in nursing, especially

in situations like this. Furthermore, I am proud of myself for stepping up and grabbing the

Doppler at the end of the intubation when the patient desatted and having the confidence to not

only assess the patient with so many other professionals in the room, but also place the OG tube.
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References

Huang, S., Yang, B., Peng, Y., Xing, Q., Wang, L., Wang, J., Zhou, X., Yao, Y., Chen, L., &

Feng, C. (2023). Clinical effectiveness of sodium bicarbonate therapy on mortality for

septic patients with acute moderate lactic acidosis. Frontiers in Pharmacology, 13,

1059285. https://doi.org/10.3389/fphar.2022.1059285

Maccagnan Pinheiro Besen, B. , Tomazini, B. & Pontes Azevedo, L. (2021). Mechanical

ventilation in septic shock. Current Opinion in Anaesthesiology, 34(2), 107-112. doi:

10.1097/ACO.0000000000000955