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

Cerebral Vascular Accident (CVA)

John Gates, 59 years old

Primary Concept

Perfusion

Interrelated Concepts (In order of emphasis) 1. Stress

2. Coping

3. Clinical Judgment

4. Patient Education

FUNDAMENTAL Reasoning: STUDENT 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 sudden

onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency

department (ED) where these symptoms continue 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 the 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:

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

RELEVANT VS data: Clinical Significance:

Current VS: P-Q-R-S-T Pain Assessment: 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 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 Fluid & Electrolytes:

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:

Current 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 and reactive to light (PEARL), 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 cut present

GI: Abdomen soft/non-tender, 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

Complete Blood Count (CBC) Current High/Low/WNL? Previous:

WBC (4.5-11.0 mm 3) 6.8 7.9

Hgb (12-16 g/dL) 14.8 16.1

Platelets(150-450x 103/µl) 228 201

Neutrophil % (42-72) 71 79

What lab results are RELEVANT a

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

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

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