A Family in Need Case Study Answer Key
© 2013 Keith Rischer/www.KeithRN.com
Unfolding Clinical Reasoning Case Study: Reply KEY
Cerebral Vascular Accident (CVA)
I. Data Collection
History of Present Trouble:
John Gates is a 59-year-one-time male who was at work when he had sudden onfix of right-sided weakness, right facial
droop, and difficulty speaking (dysarthric voice communication). He was transported to the emergency department (ED) where these
symptoms persisted. During send, he had increased agitation and became confused to place and time. It has been thirty
minutes from the onset of his neurologic symptoms when he presents to the ED.
Personal/Social History:
John lives due westith his married woman in their own home in a small rural community. He owns his ain hardware due southtore where he
remains activeastward and involved in the day-to-day operations. John's wife is with him along with his son who also piece of worksouthward in
the hardware store. His married woman insists on existence by his side and talking to John despite John'south frustration in non 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 by calendar week according to his wife.
What information from the histories is important & RELEVAnt; therefore information technology has clinical significance to the nurse?
RELEVANT Data from Present Problem:
Sudden onset of right-sided weakness, right
facial droop, and difficulty speaking
(dysarthric speech)
During transport, he had increased agitation
and defoliation to place and time
It has been xxx one thousandinutes 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 becaapply of embolism or
hemorrhagic event. Thdue east location of the affected expanse westill determine the
type and severity of symptomsouthward.
Enquire…Are we are able to localize what side of the cerebral
hemisphere this CVA is taking place on?
It is clearly the LEFT cerebral hemisphither considering of the right-sided
motor deficits. This is a adept 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 consequence and is a clinical Reddish FLAG because it is a alter
that is reflecting a worsening in status.
Has been simply 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 catamenia and limit severity
of CVA deficits dramatically. Fourth dimension IS NEURONS as it is estimated thursdayat
millions of neurons are lost every infinitesimal that tPA therapy is delayed!
RELEVANT Data from Social History:
His wife insists on being by his side and
talking to John despite John's frustration in
non existence able to answer her questions
Nicotine patch usdue east
pain on the correct pes for the past calendar week
The wife'south attitudeast 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 drag BP and should be removed
during the astute episode for now. The due northurse needs to notice it!
Be sure to take his shoes off and perform a pare and joint assessment.
Remember gout or potential for skin breakdown. He is a diabetic and
clustering these 2 pieces of clinical information requires thursdaye nurse to assess this
once the dust settles with his primary problem
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Source: https://www.studocu.com/en-us/document/rutgers-university/foundations-of-nursing-practice/answer-key-cva-unfolding-reasoning-1978/8196224
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