Case Study: ANSWER KEY 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: Sudden onset of right-sided weakness, right facial droop, and difficulty speaking (dysarthric speech) During transport, he had increased agitation and confusion to place and time It has been 30 minutes from the onset of neurologic symptoms when he presents to the ED All of these symptoms are reflecting acute neurologic changes that are due to disruption in cerebral blood flow either because of embolism or hemorrhagic event. The location of the affected area will determine the type and severity of symptoms. ASK…Are we are able to localize what side of the cerebral hemisphere this CVA is taking place on? It is clearly the LEFT cerebral hemisphere because of the right-sided motor deficits. This is a good time to highlight the relevance of A&P and remember the corpos callosum and what this does! All of these symptoms are reflecting acute neurologic changes that are due to disruption in cerebral blood flow either because of embolism or hemorrhagic event and is a clinical RED FLAG because it is a change that is reflecting a worsening in status. Has been only 30 minutes since onset of neuro symptoms. Is now in ED and if not contraindicated, he is a candidate for thrombolytic therapy such as tPA that can re-establish cerebral blood flow and limit severity of CVA deficits dramatically. TIME IS NEURONS as it is estimated that millions of neurons are lost every minute that tPA therapy is delayed! RELEVANT Data from Social History: Clinical Significance: His wife insists on being by his side and talking to John despite John’s frustration in not being able to answer her questions Nicotine patch use pain on the right foot for the past week The wife’s attitude MAY be a problem. Will need further assessment. Regarding his speech; is he expressive or receptive aphasia or both? This is reflecting EXPRESSIVE aphasia Is the patch still on him?…. May elevate BP and should be removed during the acute episode for now. The nurse needs to find it! Be sure to take his shoes off and perform a skin and joint assessment. Think gout or potential for skin breakdown. He is a diabetic and clustering these 2 pieces of clinical data requires the nurse to assess this