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:
Hx of diabetes type II and hypertension Hypertension is the leading cause for stroke and diabetes leads to vascular
changes in the body, both of these conditions increases the patient’s risk for
stroke
Sudden onset of right-sided weakness, facial These symptoms are some of the common symptoms for stroke, these
droop, and difficulty speaking deficits can correlate with the areas of the brain that the stroke occurred in
1 hour from the onset of neuro symptoms If this is an ischemic stroke, tPA can be administered within 3 hours of the
symptoms of stroke to increase the chances of recovery
RELEVANT Data from Social History: Clinical Significance:
Frustration in not being able to answer wife’s Frustration is normal for those in situation when they are having difficulty
questions speaking, it is important to try and communicate with the patient in other
way and talk to the doctor for a referral for a speech therapist to collaborate
in the patients care
Episodes of irregular rapid heartbeat The patient is experiencing periods arrythmias, which can increase the
patient’s risk for stroke due to the change in blood flow which can form
clots
Pain in his right foot Most likely caused diabetic neuropathy due to damage to the small nerve
endings in the foot, due to his uncontrolled diabetes
Cigarette smoking doubles the patient’s risk for ischemic stroke and
Trying to quit smoking --- using a nicotine increases the patient’s risk for cerebral hemorrhage
patch
Self-testing blood glucose is an important tool for managing diabetes and
Does not regularly check blood glucose and preventing complications. Since the patient is not regularly monitoring his
eats what he wants blood glucose and eats what he wants, his diabetes my be uncontrolled and
can further increase his risk for stroke
Being overweight increases the patient’s risk for stroke
BMI of 33.9
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:
RELEVANT VS data: Clinical Significance:
Pulse 118 (irregular) Tachycardia -- can disrupt normal heart function and lead to serious complications including
heart failure and stroke
BP 198/94 The patient has a Hx of HTN, this places patient at an increased risk for heart attacks and
strokes. High BP may be caused by a decrease in blood flow to the heart
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:
Hx of diabetes type II and hypertension Hypertension is the leading cause for stroke and diabetes leads to vascular
changes in the body, both of these conditions increases the patient’s risk for
stroke
Sudden onset of right-sided weakness, facial These symptoms are some of the common symptoms for stroke, these
droop, and difficulty speaking deficits can correlate with the areas of the brain that the stroke occurred in
1 hour from the onset of neuro symptoms If this is an ischemic stroke, tPA can be administered within 3 hours of the
symptoms of stroke to increase the chances of recovery
RELEVANT Data from Social History: Clinical Significance:
Frustration in not being able to answer wife’s Frustration is normal for those in situation when they are having difficulty
questions speaking, it is important to try and communicate with the patient in other
way and talk to the doctor for a referral for a speech therapist to collaborate
in the patients care
Episodes of irregular rapid heartbeat The patient is experiencing periods arrythmias, which can increase the
patient’s risk for stroke due to the change in blood flow which can form
clots
Pain in his right foot Most likely caused diabetic neuropathy due to damage to the small nerve
endings in the foot, due to his uncontrolled diabetes
Cigarette smoking doubles the patient’s risk for ischemic stroke and
Trying to quit smoking --- using a nicotine increases the patient’s risk for cerebral hemorrhage
patch
Self-testing blood glucose is an important tool for managing diabetes and
Does not regularly check blood glucose and preventing complications. Since the patient is not regularly monitoring his
eats what he wants blood glucose and eats what he wants, his diabetes my be uncontrolled and
can further increase his risk for stroke
Being overweight increases the patient’s risk for stroke
BMI of 33.9
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:
RELEVANT VS data: Clinical Significance:
Pulse 118 (irregular) Tachycardia -- can disrupt normal heart function and lead to serious complications including
heart failure and stroke
BP 198/94 The patient has a Hx of HTN, this places patient at an increased risk for heart attacks and
strokes. High BP may be caused by a decrease in blood flow to the heart
