Cerebral Vascular Accident (CVA) John Gates is a 59-year-old male -
Answered
Cerebral Vascular Accident (CVA)
I. Data Collection
History of Present Problem:
John Gates is a 59-year-old male who was at work when he had sudden onset of right-sided weakness,
right facial droop, and difficulty speaking (dysarthric speech). He was transported to the emergency
department (ED) where these symptoms persisted. During transport, he had increased agitation and
became confused to place and time. It has been 30 minutes from the onset of his neurologic symptoms
when he presents to the ED.
Personal/Social History:
John lives with his wife in their own home in a small rural community. He owns his own hardware
store where he remains active and involved in the day-to-day operations. John’s wife is with him along
with his son who also works in the hardware store. His wife insists on being by his side and talking to
John despite John’s frustration in not being able to answer her questions. John has been trying to quit
smoking over the past week and began using a nicotine patch. John has been complaining of pain on the
right foot for the past week according to his wife.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the
nurse?
RELEVANT Data from Present Clinical Significance:
Problem:
onset of right-sided weakness, right facial symptoms are reflecting acute neurologic changes that are due to
droop, and difficulty speaking disruption in cerebral blood flow either because of embolism or
hemorrhagic event.
Signs and symptoms that are reflecting neurologic changes may be
During transport, he had increased due to blockage of cerebral blood flow maybe caused by an
agitation and confusion to place and time embolism
RELEVANT Data from Social History: Clinical Significance:
, Nicotine patch use Is he still wearing the patch on him
pain on the right foot for the past week take his shoes off and perform a skin assessment. because he is a
diabetic
Lab/ diagnostic Results:
Basic Metabolic Panel (BMP) Current High/Low/WNL?
Sodium (135-145 mEq/L) 131 LOW-barely
Potassium (3.5-5.0 mEq/L) 4.1 WNL
Glucose (70-110 mg/dL) 198 HIGH
Creatinine (0.6-1.2 mg/dL) 1.5 HIGH
Complete Blood Count (CBC) Current High/Low/WNL?
WBC (4.5-11.0 mm 3) 6.8 WNL
Hgb (12-16 g/dL) 14.8 WNL
Platelets (150-450x 103/µl) 228 WNL
Neutrophil % (42-72) 71 WNL
Answered
Cerebral Vascular Accident (CVA)
I. Data Collection
History of Present Problem:
John Gates is a 59-year-old male who was at work when he had sudden onset of right-sided weakness,
right facial droop, and difficulty speaking (dysarthric speech). He was transported to the emergency
department (ED) where these symptoms persisted. During transport, he had increased agitation and
became confused to place and time. It has been 30 minutes from the onset of his neurologic symptoms
when he presents to the ED.
Personal/Social History:
John lives with his wife in their own home in a small rural community. He owns his own hardware
store where he remains active and involved in the day-to-day operations. John’s wife is with him along
with his son who also works in the hardware store. His wife insists on being by his side and talking to
John despite John’s frustration in not being able to answer her questions. John has been trying to quit
smoking over the past week and began using a nicotine patch. John has been complaining of pain on the
right foot for the past week according to his wife.
What data from the histories is important & RELEVANT; therefore it has clinical significance to the
nurse?
RELEVANT Data from Present Clinical Significance:
Problem:
onset of right-sided weakness, right facial symptoms are reflecting acute neurologic changes that are due to
droop, and difficulty speaking disruption in cerebral blood flow either because of embolism or
hemorrhagic event.
Signs and symptoms that are reflecting neurologic changes may be
During transport, he had increased due to blockage of cerebral blood flow maybe caused by an
agitation and confusion to place and time embolism
RELEVANT Data from Social History: Clinical Significance:
, Nicotine patch use Is he still wearing the patch on him
pain on the right foot for the past week take his shoes off and perform a skin assessment. because he is a
diabetic
Lab/ diagnostic Results:
Basic Metabolic Panel (BMP) Current High/Low/WNL?
Sodium (135-145 mEq/L) 131 LOW-barely
Potassium (3.5-5.0 mEq/L) 4.1 WNL
Glucose (70-110 mg/dL) 198 HIGH
Creatinine (0.6-1.2 mg/dL) 1.5 HIGH
Complete Blood Count (CBC) Current High/Low/WNL?
WBC (4.5-11.0 mm 3) 6.8 WNL
Hgb (12-16 g/dL) 14.8 WNL
Platelets (150-450x 103/µl) 228 WNL
Neutrophil % (42-72) 71 WNL
