Running head: CLINICAL EXEMPLAR: TGH BURN ICU 1

Clinical Exemplar: TGH Burn ICU

Katherine Tison

University of South Florida, College of Nursing

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Clinical Exemplar: TGH Burn ICU

Complex patients can lead to nursing experiences that are memorable an applicable to

other patients in the future. I learned from a patient I cared for two days in the Burn ICU. This

patient was a 68-year-old male with a complex cardiac and renal history. His co-morbidities

included type 2 diabetes, hyperlipidemia, early chronic kidney failure, and rheumatoid arthritis.

Despite his fair maintenance of these co-morbidities prior to the incident that brought him to

TGH Burn ICU, it seemed to be these pre-existing conditions that resulting in the steep

worsening of his condition on this particular day.

Noticing

This patient came into the ED with a sore throat and was sent home. A few days later, he

returned with a rash over 90% of his body and was diagnosed with Steven-Johnson Syndrome,

which is a very rare skin condition that is treated predominantly like a burn. After the initial

healing stage of SJS, the patient developed many complications; among them acute kidney

injury, sepsis, multi-organ failure, and presumed ischemic strokes. The patient’s family wanted to

have a clear understanding of the trauma to the patient’s brain, as they decided to continue with

only supportive and comfort measures if the patient was deemed neurologically compromised

even with recovery from other bodily conditions.

Due to the patient’s condition and with wishes of his family, the neurology team

requested a CT of the head and neck to determine neurologic damage. We travelled with our

patient and a respiratory therapist to get the CT, but every time we played the patient flat, his

oxygen quickly desaturated from the mid-90’s to the low 70’s. Multiple times, we brought him

out of the machine, rescue-bagged him, changed his vent settings, and re-attempted. Finally, we
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decided it was not possible to safely finish the procedure and consulted the critical care team to

get an order for CRRT to overload fluid from the patient, so we may finish the CT later. The

patient’s blood pressure did not tolerate CRRT well, and the dialysis team was only able to pull

one liter of fluid off. Given the circumstances, we consulted the palliative care team. The critical

care and palliative team collaborated and decided to call the family and gather a meeting.

Interpreting

The patient’s vital signs with trying to complete the CT scan required that we do

something different. We chose to stop the procedure in an effort to keep our patient safe and

consulted nephrology due to the patient’s fluid status. We notified critical care, neurology,

nephrology, and palliative care. Without responding appropriately, our patient would not survive

the procedure.

Responding

We watched and intervened appropriately until we could no longer try to progress with

the scan. The decision was made with agreement from myself, my preceptor, the respiratory

therapist, and the CT staff. It was clear the patient was not stable enough to tolerate the

procedure. At this time, we could not leave our patient and only delegated airway to the

respiratory therapist, due to inherent risks during transport of critically ill patients (Kulshrestha

& Singh, 2016).

According to Mehta and Parmar (2017), positional changes for patients with head injuries

in the ICU can dramatically increase the patient’s oxygenation status. We needed to change the

patients bed position to increase his oxygenation, but we could not do so and complete the CT

scan.
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Reflecting and Conclusion

The critical care team, neurologist, and palliative care agreed that we make the correct

decision in bringing out patient back for CRRT and facilitating a palliative care meeting with the

family. We kept our patient alive during the transport and rightly chose to end attempts to

complete the CT scan. Of course, we would have preferred that the patient could tolerate the

neurological exam. I believe we did a good job making quick decisions based on preserving the

patient’s safety. I think we could have done a better job anticipating that the patient would be

unable to tolerate the scan and plan appropriately.

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References

Kulshrestha, A., & Singh, J. (2016). Inter-hospital and intra-hospital patient transfer: Recent

concepts. Indian journal of anaesthesia, 60(7), 451–457. doi:10.4103/0019-5049.186012

Mehta, J. N., & Parmar, L. D. (2017). The effect of positional changes on oxygenation in patients

with head injury in the intensive care unit. Journal of family medicine and primary

care, 6(4), 853–858. doi:10.4103/jfmpc.jfmpc_27_17