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:
Sudden onset of right facial droop, right-sided These are signs of neurologic changes that could have been a result of a
weakness, and difficultly speaking. blockage or hemorrhage in the brain and particularly it would be the left
side since the symptoms are forming on the right side of the body.
It has only been one hour since the symptoms Since it has only been an hour he may be a candidate for tPA if not
arose. otherwise contraindicated.
RELEVANT Data from Social History: Clinical Significance:
Wife is being very persistent about staying at This could cause more stress for the patient causing further damage to the
bedside even though the patient seems agitated. brain.
He has been using a nicotine patch. Since nicotine is a stimulant, we need to figure out if the patch is still on
him as this could elevate his VS.
He has pain in his right foot for the past week. Since the patient is a diabetic, we need to check his foot for potential
wounds.
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:
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:
Sudden onset of right facial droop, right-sided These are signs of neurologic changes that could have been a result of a
weakness, and difficultly speaking. blockage or hemorrhage in the brain and particularly it would be the left
side since the symptoms are forming on the right side of the body.
It has only been one hour since the symptoms Since it has only been an hour he may be a candidate for tPA if not
arose. otherwise contraindicated.
RELEVANT Data from Social History: Clinical Significance:
Wife is being very persistent about staying at This could cause more stress for the patient causing further damage to the
bedside even though the patient seems agitated. brain.
He has been using a nicotine patch. Since nicotine is a stimulant, we need to figure out if the patch is still on
him as this could elevate his VS.
He has pain in his right foot for the past week. Since the patient is a diabetic, we need to check his foot for potential
wounds.
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:
