An exemplar is a "narrative description of a clinical situation where the nurse learned something about his/her practice or made a significant contribution to patient care". The purpose of presenting an exemplar is to share clinical knowledge and expertise and to "provide an opportunity to focus on clinical excellence, to give credit for clinical knowledge, and to acknowledge the ability of the nurse to make a difference".
Patricia Benner states, "A wealth of knowledge is embedded in the practices and the 'know how' of expert clinicians, but this knowledge will not expand or fully develop unless nurses systematically record what they learn from their own experience".
Benner and Gordon suggest the following guidelines for choosing the topic of your story:
*"What Is An Exemplar" from Write On--
Newsletter of Greater Tamp Bay Chapter
I'm a whistler. That's how I stay calm in the
midst of insanity. Of course, I drive everybody else crazy.
But sometimes--I'll be whistling "The 1812 Overture" and I'll here someone
else join in. Or I'll be whistling "Rock Around The Clock" and everybody
will start dancing...and then they all forgive my vice.
You see, I'm a Bone Marrow Transplant Nurse--have been for six years. They say the average "life expectancy" of a BMT Nurse is two years. I've been doing it for 6 years and am still hanging in there--and I think it's because of the whistling. BMT Nursing is one extraordinary challenge--ALL THE TIME!
I could tell you about the night I had two patients dieing at the same time. One was a DNR and was going within the next few hours. She was an unassuming, uneducated country girl who didn't really want to go for transplant. But her feelings had been overwhelmed by her physicians and family members--people who "knew better then her what was best".
The other one was a full code and on a Ventilator but really only had a few more days. I was Primary Nurse to both patients and felt the patients and families of both needed to be helped through this by someone they knew and who knew them.
It was an exhausting night with me running between the two rooms helping a multitude of family members deal with varying stages of grief, understanding, and acceptance without forgetting to give comfort to the patients themselves through physical contact and verbal communication. I also needed to show the family members how to still see their cherished loved one inside the ravaged body laying so distant from them on the bed.
The icing on the cake came after my first patient died and the family was in the throes of a very verbal expression of grief. My patient's husband started having chest pain, shortness of breath, and was cold and clammy. A family member said, "You know he's had a stroke before..."
After a 3 beat pause...I ushered everyone else out of the room and my wonderful team of co-workers came to my aide. The husband was already on the floor. We morbidly removed the electrodes from his deceased wife and put them on him. The House Officer came up and we did an EKG, labs, and assessments and finally decided he was allright; but that he needed to go down the street to a general hospital that had an ER for follow-up.
Even in death--this shy, frightened girl in a broken 30 year old body was overwhelmed by the people and events around her.
I didn't do a lot of whistling that night--I was too busy. But as I did post-mortem care on my patient--I whistled "Amazing Grace". She was quite religious and would have liked that.
And then it was time to go back to my other patient--who still was getting Critical Care while the family was trying to deal with the inevitability that she, too, was getting near the end of her fight.
Her mother and sister hung onto every positive thing the doctors said. The doctor had given them hope that day by
saying, "Well, her LFT's (liver function tests) are a little lower today". What he should have said was, "Her LFT's continue to be obscenely high although they came down an insignificant amount today".
As the nurse, you feel so caught in the middle when the physician isn't letting the family know how bleak the picture truly is. Who are they going to listen to?--The doctor who gives them hope?--Or the nurse full of gloom and doom?
Now I've worked side by side with BMT doctors and I see them as talented and compassionate physicians. But they are just starting when most doctors have given up--not just for palliation--they're trying to cure Cancer! So I think it makes it a little harder for most of them to give up when there truly isn't any more hope.
I spent the rest of the night trying to be honest without undermining their confidence and trust in their doctor. It's a precarious tightrope that all Oncology nurses have balanced on. Luckily, I could share my frustration with my co-workers.
And such is the life of a BMT nurse. It can't be done without the support of a great team of co-workers. When you work with an extraordinary team of Nurses under extraordinary conditions on a daily basis; I guess they're willing to put up with a goofy nurse who whistles most of the night. It makes it all just a little more sane.
Informal Exemplar Style Cases Study:
This was part exemplar/part case study that
has been modified with questions to be a simple case study. If you wish
to just write down a patient situation without developing the questions—we
will do that for you too.
Hot, Hot, Hot!
Highest Fever Case Study
By Rosie El-Rady, RN,BSN, MSN/NP student
At noon, we got word that a post-transplant patient on 3 North needed to come over to our side for intensive care. Jackie was a 28-year-old CML patient who was over 300 days post-allogeneic transplant. Her transplant admission had been uneventful, but since then she had been in and out of the hospital many times with non-neutropenic fevers and no positive cultures.
What labs would you want to draw?
Jackie’s Labs: WBC 2.0
Rest of Chemistry WNL
DIC Panel WNL
What other labs would you want to draw? What
do the above results mean to you?
Patient’s labs are all low—but not critically
so. The only lab needing direct intervention is the low Magnesium. The
physician should have already ordered emperic antibiotic coverage.
Blood Cultures were drawn from the central line and peripherally.
All prior cultures had been negative.
I volunteered to take Jackie who came over after 1:00 p.m. rigoring in her bed with a fever of 40.4 degrees Celsius.
What would you anticipate with this temperature?
What questions would you want to ask yourself?
What is her mentation? (Decreased level of consciousness (LOC) is an early indicator of oxygenation). What is her BP? (Decreased BP reflects decreased cardiac output and 3rd spacing causing intravascular hypovolemia due to Sepsis)
She was alert and oriented to self and place but not to time. She was wearing a nasal cannula and receiving oxygen at 2L/m for extra support under this stressful situation. Her BP had started dropping (to a low of 87 systolic).
What would be your preferred first treatment
for decreasing BP?
Fluid bolus. 0.9% Sodium Chloride (NS).
Check the patient’s respiratory status. If they can tolerate it—you can give 250 – 500 ml at a time. If they are “wet” you would be safer to give the fluid in 100 ml increments.
Are there any signs of 3rd spacing? (Edema, ascities, fluid in lungs?) If so—you may need to alternate bolus/Diuretic/fluid/Diuretic. Another possibility would be Albumin to help pull the fluid back into the vasculature and then give a Diuretic.
She was just finishing up a 500 ml fluid bolus. Once placed on the cardiac monitor, we saw she was in sinus tachycardia at rates of 110 – 140 depending on activity, and her SBP had risen to the high 90s.
Why do you think her heart rate is increased?
Why is her BP higher?
Fever, decreased oxygenation, and decreased Cardiac Output with Hypotension will cause the heart rate to increase. Hypovolemia does the same thing. The body is trying to compensate for less vascular fluid, lower BP, and lower oxygen by moving the blood left in the veins more quickly. She also may be starting to respond to the fluid bolus.
We continued IV hydration with NS at 150 cc/hr, and I gave
her Demerol 25 mg IV for the rigoring. I then continued to try to get all
her antibiotics in (she was being covered for every possible organism),
fit in her first high-dose Solumedrol piggyback and her magnesium bolus,
all the time fearing that the other shoe was going to drop if I didn’t
get all these meds in her system in a timely manner. She had no external
signs of infection, was voiding, and was very thirsty because of the fever-induced
dehydration—all favorable signs under the circumstances.
When her fever rose to 40.9 degrees Celcius around 2:30 p.m., Tylenol had already been given…
What else would you do for her fever?
Some physicians use cooling blankets—but this is controversial. This can actually make the temperature go up by chilling the patient and making them rigor (which drives the temp up). Tepid (not cold) sponge baths can actually do more good. Remember that the patient’s temp is high. If “normal” is 98.6 F.—then even that temp is “cool” to the febrile patient.
…so we put ice packs on her & ordered a cooling blanket STAT. Surprisingly we got it right away, placed it on Jackie, and started frequent oral temperatures. Thirty minutes later I was surprised again—this time unpleasantly. I found that her fever was even higher—41.7 degrees Celcius. By that time her rigors had resumed. I was concerned that the cooling blanket was worsening the situation. Had it caused the new onset of rigors and the increase in fever? I asked Dr. T. what to do, and she instructed me to keep the blanket on.
What else could you do?
You could give more Demerol (at 25 mg increments). This is the only place in the Oncology setting where Demerol is used.
A colleague, Mike, was helping me by then and suggested another
dose of Demerol. We had to stop the rigoring to stop the steep rise in
her temperature. Jackie received the next dose of Demerol while we were
struggling to fix the electronic BP cuff, which had failed on us…not good
when you’re concerned about septic shock.
A couple of manual BPs taken shortly after were in the low 80s…
Now what could you do for the low BP?
If you have critical care capabilities—you could start Dopamine at > 3 – 5 mcg/kg/min and titrate for SBP > 90 and MAP >60. You need a mean arterial BP (MAP) of at least 60 for renal perfusion. (70 is optimal) If the BP is truly deteriorating or if you find yourself having to rapidly titrate the Dopamine up—a better choice may be Levophed with Dopamine kept < 3 mcg/kg/min to help renal perfusion. (ACLS recommends starting with Levo if the SBP is in the 70s).
…so Jackie’s PA (Physician's Assistant) ordered Dopamine to keep
SBP > 90.
Luckily, Jackie held her own & did not need the Dopamine, and 6 hours from her transfer to the unit, Jackie’s fever finally came down to a cool 37.6 degrees Celsius. It was 7:30 p.m., the end of a long shift, and the conclusion of one HOT day.
What do you think turned Jackie around?
The nurse was diligent to get the antibiotics started ASAP. She also gave fluid boluses and Demerol to lower the elevated temp that would elevate itself when Jackie had more rigors. (A vicious circle) Jackie may not be totally out of the woods yet—but in the BMTU she is being closely monitored and assessed and any new developments will be rapidly addressed…
This was originally an exemplar which gives the narrative a more
personal flavor then the typical case study. Usually, they are more cut
and dried. Either way would be appropriate.
Before the workbook is completed—we would like to add footnotes supporting the rationale of the “answers”. We would also fine-tune the final draft after peer review is completed.
This is a more formal approach:
SOAPIE Format for Case Studies:
Subjective (where applicable):
History of Present Illness
Initial lab work & relevant results
Initial diagnostic studies & relevant results
Past Medical/Surgical History
Review of Systems
Physical Examination (relevant findings for chief complaint)
Throughout this format you can ask (or we can
add) pertinent questions (with suggested answers) to stimulate thought.
Try to list references if possible and applicable. These can be books or articles you have read, or seminars, lectures, or classes you have attended at work. You can also source internet sites.
If all you want to do is present your case without the additional work—that is fine too.
If we decided to make any revisions to your original work--we would first ask for your permission.