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:

Patient Care Begins: T: 99.2 F/37.3 C (oral)

P: 118 (irregular)
R: 20 (regular)
BP: 198/94
O2 sat: 99% room air

Provoking/Palliative: Quality: Region/Radiation: Severity:

Unable

Current VS:

P-Q-R-S-T Pain Assessment (5th VS):

Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS data:	Clinical Significance:

© 2016 Keith Rischer/www.KeithRN.com

Current Assessment:

GENERAL APPEARANCE: RESP: CARDIAC:

GI:

GU: SKIN:

Appears anxious-he is aware and appears to be concerned about changes in neuro status

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort 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

Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Able to swallow saliva
Voiding without difficulty, 700 mL urine clear/yellow,
Skin integrity appears intact, right foot not assessed at this time

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

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT assessment data:	Clinical Significance:

Cardiac Telemetry Strip:

Interpretation:

Clinical Significance:

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

© 2016 Keith Rischer/www.KeithRN.com

Lab Results:

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:

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

PT/INR (0.9-1.1 nmol/L) 1.1 n/a

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

Coag

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:

 

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