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
, 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:
Type 2 DM Because John has a history of type 2 DM and HTN, he is at a greater
HTN risk of having a stroke. His present symptoms have me suspect that
Right sided weakness, right facial droop, he is experiencing a left hemisphere CVA, but would need further
aphasia testing such as a head CT to confirm.
RELEVANT Data from Social History: Clinical Significance:
“heart felt as if it were beating irregularly” John’s social history puts him at risk of having a CVA. He is a
c/o pain in right foot diabetic who used to smoke, his glucose is out of control and he is
Former smoker, but quit and is using overweight. He also may have undiagnosed atrial fibrillation based
patches on his description of his heartbeat. His age and gender also put him
Does not check glucose, eats what he wants at a higher risk of having a stroke, but those are non-modifiable risk
Overweight factors.
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:
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
, 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:
Type 2 DM Because John has a history of type 2 DM and HTN, he is at a greater
HTN risk of having a stroke. His present symptoms have me suspect that
Right sided weakness, right facial droop, he is experiencing a left hemisphere CVA, but would need further
aphasia testing such as a head CT to confirm.
RELEVANT Data from Social History: Clinical Significance:
“heart felt as if it were beating irregularly” John’s social history puts him at risk of having a CVA. He is a
c/o pain in right foot diabetic who used to smoke, his glucose is out of control and he is
Former smoker, but quit and is using overweight. He also may have undiagnosed atrial fibrillation based
patches on his description of his heartbeat. His age and gender also put him
Does not check glucose, eats what he wants at a higher risk of having a stroke, but those are non-modifiable risk
Overweight factors.
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:
