Fundamental Reasoning: Student Cerebral Vascular Accident (CVA)

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Fundamental Reasoning: Student Cerebral Vascular Accident (CVA) Essay Assignment Paper

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 and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

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

RELEVANT Lab(s): Clinical Significance: TREND: Improve/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

Basic Metabolic Panel (BMP) Current High/Low/WNL? Previous:

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

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?

(Relate initial manifestations to the pathophysiology of the 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 type II-poorly controlled

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 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 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

Alteplase IV dose per pharmacy

(if CT 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″ to keep SBP

160-180

3. CT head stat

4. Cardiac monitor continuous

5. Alteplase IV (if CT 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 Interventions: 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 & 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 the 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?

RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Current VS:
PQRST Pain Assessment:
P 118 irregular:
UnableQuality:
R 20 regular:
UnableRegionRadiation:
BP 19894:
UnableSeverity:
UnableTiming:
RELEVANT VS dataRow1:
Clinical SignificanceRow1_3:
Current Assessment:
Appears anxioushe is aware and appears to be concerned about changes in neuro status:
RESP:
CARDIAC:
NEURO:
GI:
GU:
Voiding without difficulty 700 mL urine clearyellow:
SKIN:
RELEVANT assessment dataRow1:
Clinical SignificanceRow1_4:
Clinical SignificanceNo abnormalities noted no mass no bleed no shift present:
Current:
Previous:
WBC 45110 mm 3:
HighLowWNL68:
79:
Hgb 1216 gdL:
HighLowWNL148:
161:
HighLowWNL228:
201:
Neutrophil 4272:
HighLowWNL71:
79_2:
RELEVANT LabsRow1:
Clinical SignificanceRow1_5:
TREND ImproveWorseningStableRow1:
Current_2:
Previous_2:
HighLowWNL133:
139:
HighLowWNL41:
45:
Glucose 70110 mgdL:
HighLowWNL222:
128:
HighLowWNL15:
15Coag:
HighLowWNLCoag:
11Coag:
HighLowWNL11:
na:
RELEVANT LabsRow1_2:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1_2:
Lab:
Creatinine Value 15:
Why RelevantRED FLAG:
Nursing AssessmentsInterventions RequiredRED FLAG:
Home Med:
ClassificationIndomethacin:
Mechanism of Action in own wordsIndomethacin:
Nursing ConsiderationsIndomethacin:
ClassificationAspirin:
Mechanism of Action in own wordsAspirin:
Metformin:
Pathophysiology of Primary ProblemRow1:
RationaleRelationship to ManifestationsRow1:
Past Medical History PMH:
Home Meds:
Lisinopril Indomethacin Aspirin Metformin Simvastatin:
PMH:
What Came FIRST:
What then followed:
Care Provider Orders:
How it Will Resolve Primary ProblemNursing PriorityEstablish peripheral IV 12 lead EKG stat Labetalol 1020 mg IV prn every 15 minutes to keep SBP 160180 CT head stat Cardiac monitor continuous NPO Alteplase IV dose per pharmacy if CT negative for bleed:
Order of Priority1Establish peripheral IV 2Labetalol 1020 mg IV prn every 15 to keep SBP 160180 3CT head stat 4Cardiac monitor continuous 5 Alteplase IV if CT negative for bleed:
Rationale1Establish peripheral IV 2Labetalol 1020 mg IV prn every 15 to keep SBP 160180 3CT head stat 4Cardiac monitor continuous 5 Alteplase IV if CT negative for bleed:
Nursing PriorityRow1:
Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
Lisinopril:
Simvastatin:
Mechanism of Action:
Nursing ConsiderationsAspirin:
Text7:
Text8:
Text9:
Text10:
Text11:
Text12:
Text13:

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