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Running Head: CLINICAL EXEMPLAR

Patient Advocacy Clinical Exemplar

Kimberly Tavares
University of South Florida

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CLINICAL EXEMPLAR

A clinical exemplar is meant to showcase exemplary nursing care and judgement. These
exemplars display acquisition of knowledge, review assessment skills and early warning signs in
patients, identify unrecognized facets of nursing and outstanding situations in nursing practice.
The purpose is to relay a story in which a significant difference was made on the patients behalf
(Giordano, 1996).
This clinical exemplar is based on therapeutic communication and believe the patient is
not fabricating or exaggerating symptoms and complaints. I had a particular patient with
pulmonary hypertension whose treatment for this disease process had the side effect of extreme
nasal congestion. Comorbidities for this patient included COPD, which did not make his
breathing efforts any better. Upon arriving for my shift, this patient was on BiPAP due to
difficulty in breathing overnight. When trying to switch to the nasal cannula, his oxygenation fell
into lower into the eighties with complaints of dyspnea. This patient needed a venturi mask to
keep his oxygen saturations at or above 89, as the provider suggested. The patient requested a
decongestant spray, stating he uses it multiple times a day at home. The team denied the request,
with the reasoning that he would continue to get rebound congestion. The patient refused his
pulmonary hypertension medication due to the side effect of congestion. He felt that not being
able to breathe was far more anxiety inducing than having worsening pulmonary hypertension.
Throughout the day, the bridge of his nose and face started to become red and the skin
breakdown was probable. The patient became increasingly agitated with multiple requests for the
decongestant nasal spray. He stated that he knew of the possibility of rebound congestion and he
did not care. The patient said he just wanted to be able to breathe and not being able to breathe
was the worst feeling in the world. I relayed his concerns to the team, who ordered a Q6 dosage
for only 3 days. The patient was not happy about this. His frustrations were heard throughout the

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CLINICAL EXEMPLAR

healthcare team including the RN, residents, interns, respiratory therapists and other attending
physicians that were not his primary management. Most regarded him as being an ornery, old
man that was noncompliant. I listened to his concerns and heard him out. In the same day, this
man refused a right-sided heart cath procedure. In one day, my patient had refused two very
important aspects of his hospitalization and care. Through therapeutic communication and
speaking with the patient I realized some of his concerns and fears related to his medication and
procedure plan. Some of the healthcare team members were ready to write him off and let him
get away with refusal of treatment. I advocated on his behalf with the attending was rounding
and brought it to his attention that my patient does not want to become sicker, however some of
the side effects of his medication and previous heart cath procedures are unbearable. The
attending realized this genuine concern and spoke with my patient about the procedure for quite
some time. After the attending physician left, my patient began to cry tears of happiness. He
found out that this new medication regimen and heart procedure could mean that he could start to
feel better.
At the end of the day, the consent for the right heart cath procedure was signed and his
evening dose of pulmonary hypertension medication was taken. My patient went from being
labeled as a mean, angry, grumpy man to a grandfather trying to get better for his grandchildren
and future. Therapeutic communication and advocacy played a big part and solving the deeper
issues. Although decongestant nose spray does cause rebound congestion if used longer than
three days, it did not matter in this case because as long as the patient could breathe long enough
to hear the treatment plan out, it meant that his medication regimen could be altered so that he
might not have this problem in the future. I followed up with this case and heard the procedure
went fine and he was transferred out to the floor.

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CLINICAL EXEMPLAR

References
Giordano, B. P. (1996). Clinical exemplars demonstrate perioperative nurses' courage and
commitment to quality patient care. AORN Journal, 63(1), 15-18. doi:10.1016/s00012092(06)63418-2