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Nursing 1301 - Cerebral Vascular Accident (CVA). John Gates is a 59-year-old male. Case Study.

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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 Problem: Clinical Significance: onset of right-sided weakness, right facial droop, and difficulty speaking During transport, he had increased agitation and confusion to place and time symptoms are reflecting acute neurologic changes that are due to disruption in cerebral blood flow either because of embolism or hemorrhagic event. Signs and symptoms that are reflecting neurologic changes may be due to blockage of cerebral blood flow maybe caused by an embolism RELEVANT Data from Social History: Clinical Significance:


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