Running head: CLINICAL EXEMPLAR OF NSICU PRECEPTORSHIP

Clinical Exemplar from Preceptorship in Neuroscience Intensive Care Unit

Shawn Hekkanen
University of South Florida

CLINICAL EXEMPLAR OF NSICU PRECEPTORSHIP

Clinical Exemplar from Preceptorship in Neuroscience Intensive Care Unit

Below is my clinical exemplar that relates a formative experience from my preceptorship
(Wallace, 2016). I gained many great experiences with patients and families. However, this early
experience, my second shift during preceptorship, clued me into the benefits of having an
excellent nurse on the Neuroscience Intensive Care Unit (NSICU).
A 31-year-old female patient with no neurological history except migraines was
diagnosed with 7mm aneurysm at a bifurcation. Symptoms upon hospital admission included
headache with right eye vision that cycled between darkened and cloudy. This patient was
alert and oriented prior to surgery. The patient and her large family appeared unfamiliar with
hospitals and acted collectively bewildered by her condition. However, her father had history of
an aneurysm. For my patient, the neurosurgery team used the clipping surgical technique without
complications. After surgery, the patient had an arterial line with order to keep systolic pressure
below 140 mmHg. Hourly neurological assessments were performed. Incisions were open to air.
Sleep was promoted between assessment and care. She was assisted with ice chips to relieve dry
throat. Her first two neural assessments were alert and oriented x 4, but reporting severe pain 89. An ordered post-operative computed tomography (CT) scan had originally been intended
prior to transfer back to NSICU. The scan had not been performed, and the mobile CT was
delayed.
With husband as chaperone, the family was taken into the room by groups of three. The
husband was educated that touching, talking, lighting, and other stimulation may cause increases
in blood pressure (BP) and intracranial pressure. However, the family wanted to caress the
patients hand, attempt to question the patient, loud talking, etcetera. The third neural check
revealed a significant change, now having orientation to person only. Deficits included delayed

CLINICAL EXEMPLAR OF NSICU PRECEPTORSHIP

responses, repetitive speech, agnosia, and difficulty following commands. The rest of the
treatment team was notified immediately.
Prior to the sudden change, there had been a delay with pharmacy for several medication
orders to be released, including opiate, benzodiazepine, and steroid. With the sudden orientation
deficit, the patient was continually assessed for hemorrhage, including increased vital sign
assessments and neural checks. Pressures were monitored very closely. The post-operative CT
scan was prioritized.
The neurosurgery team arrived and performed additional neurological assessments,
including having the patient sit up, attempt to identify a wristwatch and its function, and puffing
out her cheeks. Patient awkwardly sat up. Instead of identifying the wristwatch, she was tapping
it in imitation of the surgeon. Her cheeks were symmetrical. Apparent cognitive deficits were
believed to indicate brain swelling instead of hemorrhage. The CT scan supported swelling.
Decadron, pain medication, and control of stimulation were prioritized to help reduce
inflammation.
Ultimately, this one event foreshadowed the great respect that I developed for the
NSICU culture and their patient-centered care. During preceptorship, I learned much about
coordination of care amongst multiple providers. I was even privileged to observe the
neurosurgery morning meeting include nursing documentation into discussion. With any nursing
department, I hope to be a part of a similar outstanding culture. To observe and participate in
expert-level nursing was a privilege.

CLINICAL EXEMPLAR OF NSICU PRECEPTORSHIP

References
Wallace, J. (2016). Nursing Student Work-Study Internship Program: An Academic Partnership.
Journal Of Nursing Education, 55(6), 357-359 3p. doi:10.3928/01484834-20160516-11