Running head: CLINICAL EXAMPALAR 1

Clinical Exemplar

Vaishali Amin

University of South Florida

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Background

65-Year-old male presented to the hospital for lower back pain. Patient was having difficulty

bending and lifting due to lower back pain. The pain was seven out of ten on the pain scale, the pain was

characterized as pulling, throbbing, tight and it began approximately one and half year ago. Patient tried

heat and over the counter medications to try and resolve the symptoms but was unsuccessful. Patient

went to a primary care physician, who prescribed narcotics to help alleviate the pain, however after doing

further testing, patient consulted about surgery. Patient underwent a L2-S1 PLIF.

Patient Care

I met the patient Post op day one on floor four south at the James A Haley hospital. During the

morning assessment. I noticed that the patient had a soft, distended abdomen and patient stated he felt a

lot of pressure in the abdomen. Patient had not had a bowel movement since before the surgery. Patient

had lost blood during the procedure, the nurse during the handoff stated they had given the patient two

units of blood right after the procedure. I looked up the lab and saw that hemoglobin was at 7.2, which

improved after the two units of bloods were administered. Post op day 2 patient was unable to ambulate

due to fatigue and low blood pressure. Post op day 3, Patient still did not have a bowel movement and

now the patient’s abdomen was distended and hard. Patient was administered an enema and given

docusate, but the patients abdomen remained distended through my shift. Post op day 4- hemoglobin was

elevated, however the patient had multiple watery bowel movements, and patient was placed on liquid

diet.

For this patient, I started to realize that he was weak and lethargic due to the loss of blood during

the surgery. I was concerned about paralytic ileus which is a known complication after spinal operation.

The enema was sodium phosphate, a saline laxative that exerts osmotic effect in the small intestines by

drawing water into the lumen of the gut, producing distention and promoting peristalsis and evacuation of

the bowel. Patient was also on a liquid diet, which didn’t give him a lot of protein and carbs, to help heal

and build up energy. The distention and diarrhea were immediately reported to the surgery team, and
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before I could finish suggesting a KUB, the surgery team placed in an order for a KUB STAT to rule out

any obstruction in the abdomen that could be causing the distention. Although paralytic ileus is

considered an early and minor complication after spinal surgery, it could affect one’s quality of life

during postoperative rehabilitation. (Oh, et al., 2015). According to Oh, et al. (2015), delay in the

diagnosis of paralytic ileus can result in serious complications and even death. I as a student was glad

that the KUB was done and the results were negative for obstruction of bowels.

Patients continued to be lethargic and weak. Patients labs were drawn, and I knew that their would-be

electrolyte imbalance due to multiple diarrheal bowel movements. Lab results reported potassium at 3.2,

which is well below normal values of 3.5-5.2. Patients team was contacted, and we requested that patient

be placed on potassium as soon as possible and orders for telemetry be place to monitor the patient’s heart

rhymes. Patient was placed on oral and IV potassium with additional fluids to help with rehydration.

EKG was conducted to ensure that the low potassium did not cause heart arrythmias. There was not

much I could do besides wait and see if the potassium was helping, I did have to monitor the rate because

the patient was sensitive and felt a burning sensation, for which learning from class I slowed down the

rate of infusion that was tolerated by patient. Patient was kept hydrated and bed pan close by to ensure he

did not fall off bed. Patient began to feel better and stronger. I requested that since the patient tolerated

the liquid diet that it should be advanced to mechanical. EKG had normalized, and electrolytes were

within normal limits. Patient was monitored and reassessed frequently.

Patient Education

While I sat close by outside doing my notes, I decided to take my computer into the room and

start up a conversation about his health history. I realized that while my patient is in bed and alert, this

would be the perfect time to conduct some patient education. Patient education is a term that includes

patient teaching, advice and information-giving, behavior modification techniques, and involves two-way

communication between the nurse and the patient aimed at maintaining or improving health or learning to

cope with their condition (Crawford, Roger, & Candlin, 2017).

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I was able to educate the patient on what happens after back surgery and provide vital education on the

medications that I administered and why they were ordered. I was able to explain why the potassium was

given to him and how the enema caused the potassium deficit to begin with. I encouraged and educated

patient that walking was the best way to jumpstart gastic motility and I believe because of explaining and

empowering the patient, he patient started to sit up in chair and walk with assistance around the nurse’s

station. Patient education has long been recognized as an important part of a nurse’s role, and this is

increasingly so with an aging population, shorter hospital stays, and an increasing prevalence of chronic

disease and complex health problems (Crawford, Roger, & Candlin, 2017). Patient was able to also let

the surgery team know that he needed to gain strength and that he would like to be placed in rehab.

Empowerment in patient education is a model that has been used increasingly in recent years as education

offered with this approach has been found to influence patients’ self-efficacy, quality of life and

participation in decision-making (Crawford, Roger, & Candlin, 2017).

By the end of my shift, I saw the impact I had on this patient. He wanted to improve his quality

of life, he wanted to ambulate more than just one time around the nurse’s station, he was more vigilant

and asked more questions about medications and procedures. Patient felt much better by the end of my

shift and even asked to place the back brace on so that he can ambulate to the bathroom himself and be

more independent.

Conclusion

As nurses, we have all this knowledge that school has instilled in us, but that we get caught up in

the act of taking care of the patient without taking the time to empower them to want to get better. I

believe that providing bedside patient education and allowing the time for the patient to ask questions and

then seeing them become more involved in their own care was the moment I realized what impact I had

on patients. I believe that the more comfortable I get to repeating and stating the things I’ve learned at

University of South Florida to my patient, the more confident I feel that I can improve health outcomes

for my future patients. Every patient is different, and each patient has a different learning style, I believe

that taking the time to learn what motivates a patient is key to having a successful recovery.
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References

Crawford, T., Roger, P., & Candlin, S. (2017). The interactional consequences of ‘empowering

discourse’ in intercultural patient education. Patient Education and Counseling,100(3), 495-

500. doi:10.1016/j.pec.2016.09.017

Oh, C. H., Ji, G. Y., Yoon, S. H., Hyun, D., Park, H., & Kim, Y. J. (2015). Paralytic Ileus and

Prophylactic Gastrointestinal Motility Medication after Spinal Operation. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630052/