lOMoARcPSD|3013804
CVA Unfolding Reasoning WK3
NR 324 ADULT HEALTH (Chamberlain
University)
, lOMoARcPSD|3013804
Cerebral Vascular Accident (CVA)
John Gates, 59 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Clinical Judgment
4. Patient Education
5. Communication
6. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, lOMoARcPSD|3013804
UNFOLDING Clinical Reasoning Case Study: STUDENT
Cerebral Vascular Accident (CVA)
History of Present Problem:
John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had
sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency
department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic
symptoms when he presents to the ED. You are the nurse responsible for his care.
Personal/Social History:
John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains
active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s
frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of
episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has
been complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has
been using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants.
He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9).
What data from the histories are RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
onset of right-sided weakness, right facial droop, and difficulty symptoms are reflecting acute neurological changes that are due to disruption in cerebral blood flow either because
of embolism or
speaking hemorrhagic event.
one hour onset
Signs and symptoms that are reflecting neurological changes may be due to blockage of cerebral blood flow maybe
caused by an
embolism
RELEVANT Data from Social History: Clinical Significance:
Nicotine patch Is he still wearing the patch on him, it is a vasconstrictor and can
use agitation elevate the BP.
heart beating irregular and fast in his
chest pain on the right foot for the past a fib can cause a clot and give the symptoms he explained
week take his shoes off and perform a skin assessment. because he is a
does not check blood sugar and eats what diabetic and poorly compliant diabetic
ever he wants may not have the best sources to medical care in a rural community
lives in a rural community
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable
P: 118 (irregular) Quality:
R: 20 (regular) Region/Radiation:
BP: 198/94 Severity:
O2 sat: 99% room air Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS data: Clinical Significance:
99.2 slightly elevated possible infection
118 irreg abnormal high and irregular
198/94 abnormal high D&S both could be an indicator of pain and or anxiety
(doom feeling).
however he also is a non compliant diabetic. also common cause of
strokes is A fib
also high blood pressure can cause a decreased blood flow and could have
CVA Unfolding Reasoning WK3
NR 324 ADULT HEALTH (Chamberlain
University)
, lOMoARcPSD|3013804
Cerebral Vascular Accident (CVA)
John Gates, 59 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Stress
2. Coping
3. Clinical Judgment
4. Patient Education
5. Communication
6. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, lOMoARcPSD|3013804
UNFOLDING Clinical Reasoning Case Study: STUDENT
Cerebral Vascular Accident (CVA)
History of Present Problem:
John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had
sudden onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency
department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic
symptoms when he presents to the ED. You are the nurse responsible for his care.
Personal/Social History:
John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains
active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s
frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of
episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has
been complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has
been using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants.
He is 6 feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9).
What data from the histories are RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
onset of right-sided weakness, right facial droop, and difficulty symptoms are reflecting acute neurological changes that are due to disruption in cerebral blood flow either because
of embolism or
speaking hemorrhagic event.
one hour onset
Signs and symptoms that are reflecting neurological changes may be due to blockage of cerebral blood flow maybe
caused by an
embolism
RELEVANT Data from Social History: Clinical Significance:
Nicotine patch Is he still wearing the patch on him, it is a vasconstrictor and can
use agitation elevate the BP.
heart beating irregular and fast in his
chest pain on the right foot for the past a fib can cause a clot and give the symptoms he explained
week take his shoes off and perform a skin assessment. because he is a
does not check blood sugar and eats what diabetic and poorly compliant diabetic
ever he wants may not have the best sources to medical care in a rural community
lives in a rural community
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable
P: 118 (irregular) Quality:
R: 20 (regular) Region/Radiation:
BP: 198/94 Severity:
O2 sat: 99% room air Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS data: Clinical Significance:
99.2 slightly elevated possible infection
118 irreg abnormal high and irregular
198/94 abnormal high D&S both could be an indicator of pain and or anxiety
(doom feeling).
however he also is a non compliant diabetic. also common cause of
strokes is A fib
also high blood pressure can cause a decreased blood flow and could have
