NR 304 Case Study Week 5 Cerebral Vascular Accident (CVA) 

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Cerebral Vascular Accident (CVA)

Case Study

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 a sudden onset of right-sided weakness, right facial droop, and difficulty speaking.   He was transported to the emergency department (ED) where these symptoms continued 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 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:
RELEVANT Data from Social History:	Clinical Significance:

 

Developing Nurse Thinking by Identifying Significance of Clinical Data

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 are RELEVANT and must be recognized as clinically significant by the nurse?

Relevant VS data:	Clinical Significance:

 

General Assessment:
GENERAL APPEARANCE:	Appears anxious-he is aware and appears to be concerned about changes in neuro status
RESP:	Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC:	Pink, warm & dry, no edema, heart sounds irregular -S1S2, telemetry rhythm is atrial fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:	Is anxious, restless and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal round and reactive to light (PERRL), both right upper extremity (RUE) and right lower extremity (RLE) notably weak (3/5) in comparison to left, which is strong 5/5, right pronator drift present, unable to hold right arm up, right visual deficit present.
GI:	Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants.  Able to swallow saliva
GU:	Voiding without difficulty, 700 mL urine clear/yellow
SKIN:	Skin integrity appears intact, right foot not assessed at this time.

 

What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?

RELEVANT assessment data:	Clinical significance:

 

 

Developing Nurse Thinking through APPLICATION of the Sciences:

Lab/diagnostic Results:

Radiology Reports:  Head CT

What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT results:	Clinical significance:
No abnormalities noted, no mass, no bleed, no shift present

 

Lab Results:

Complete blood count (CBC)	Current	High/Low/WNL?	3 hours ago
WBC (4.5-11.0 mm3)	6.8		7.9
Hgb (12-16 g/dL)	14.8		16.1
Platelets (150-450×103/µl)	228		201
Neutrophil %(42-72)	71		79

What CBC lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT labs:		Clinical Significance		TREND:  Improve/Worsening/Stable
Basic Metabolic Panel (BMP)	Current		High/Low/WNL?		3 hours ago
Sodium (135-145 mEq/L)	133				139
Potassium (3.5-5.0 mEq/L)	4.1				4.5
Glucose (70-110 mg/dL)	222				128
Creatinine (0.6-1.2 mg/dL)	1.5				1.1
Coag
PT/INR (0.9-1.1 nmol/L)	1.1				n/a

What BMP lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Labs:	Clinical Significance	TREND:  Improving/Worsening/Stable

 

 

Lab Planning:  Creating a Plan of Care with a PRIORITY lab:

Lab:	Normal Value	Why Relevant?	Nursing Assessments/Interventions Required
Creatinine   Value:  1.5	Red Flag:

 

 

Pharmacology:

Home Med:	Classification	Mechanism of Action (in own words)	Nursing Considerations
Indomethacin
Aspirin
Lisinopril
Simvastatin
Metformin

 

PATHOPHYSIOLOGY:

1. What is the primary problem that your patient is most likely presenting?

 

 

2. What is the underlying cause/pathophysiology of this primary problem?

 

 

 

Pathophysiology of Primary Problem:	Rationale/Relationship to Manifestations:

 

Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS

1. What is the RELATIONSHIP of the past medical history and current medications? (Which medication treats which condition?  Draw lines to connect)

Past Medical History (PMH)	Home Meds:
Diabetes Mellitus Hypertension Hyperlipidemia Gouty arthritis Smokes 1 ppd x 40 years	Lisinopril Indomethacin Aspirin Metformin Simvastatin

 

2. Is there a RELATIONSHIP between any disease in PMH that may have been contributed to the development of the current problem? (Which disease likely developed FIRST then began a ‘domino effect”?)

PMH:	What Came FIRST?
Diabetes mellitus Type II -poorly controlled Hypertension Hyperlipidemia Gouty arthritis Smokes 1 ppd x 40 years	What then followed:

 

 

3. What is the RELATIONSHIP between the primary care provider’s orders and the primary problem?

Care Provider Orders:	How it Will Resolve Primary Problem/Nursing Priority:
Establish peripheral IV       12 Lead EKG stat       Labetalol 10-20 mg IV prn every 15 minutes to keep SBP 160-180       CT head stat       Cardiac monitor continuous       NPO       Alteplace IV dose per pharmacy (if CT head negative for bleed)

 

 

Developing Nurse Thinking by Identifying Clinical PRIORITIES

1. Which Orders Do You Implement First and Why?

Care Provider Orders:	Order of Priority:	Rationale:
1.      Establish peripheral IV   2.     Labetalol 10-20 mg IV prn every 15 min to keep SBP 160-180   3.     CT head stat   4.     Cardiac monitor continuous   5.     Alteplase IV (if CT head negative for bleed)

 

2. What nursing priority(ies) will guide your plan of care? (If more than one, list in order of PRIORITY)

 

 

 

 

 

 

 

 

3. What interventions will you initiate based on this priority?

Nursing Priority	Nursing Intervention	Rationale:	Expected Outcome:

 

4. What are the PRIORITY psychosocial needs that this patient and/or family likely have that will need to be addressed?

 

5. How can the nurse address these psychosocial needs?

 

 

6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?

 

 

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

 

2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?

 

 

 

Use REFLECTION to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is a nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment and transfer what is learned to improve nurse thinking and patient care in the future.

1. What did I learn from this scenario?

 

 

2. How can I use what has been learned from this scenario to improve patient care in the future?