Running head: TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

Typical Patient Case and Comprehensive Guide for Holistic Assessment for the Adult CVA
Survivor Population
Tracy Terrones
University of Arizona

Typical Patient Case and Comprehensive Guide for Holistic Assessment for the Adult CVA
Survivor Population
Patient-Based Case Study
A 32-year-old female patient presents on Christmas morning 2015 to the Emergency
Department (ED) by ambulance with right sided facial drooping, right arm/leg weakness, severe
headache, and slurred speech. This young female is a single mother of two children and a fulltime register nurse (R.N.). Patient has history of hypertension, anxiety, depression, supra
ventricular tachycardia (SVT), proximal atrial fibrillation and body mass index (BMI) of 34.

Currently she is on oral contraceptives and smokes 10 cigarettes per day. Family past medical
history is positive for hypertension, diabetes and dyslipidemia. These comorbidities create a
trifecta for a neurologic event. Upon arrival to the ED the patient exhibited elevated BP of
180/100, severe headache, and inability to answer appropriately.
The morning of the event as she was making breakfast, her daughter noticed her mothers
face suddenly looked funny and she acted scary. The child immediately called 911. As the
first responders and paramedics arrived, they instantly assessed the patient for signs of a cerebral
vascular accident (CVA), onset of symptoms less than 3 hours, and notified the ED. A set of
vitals were obtained blood pressure 180/100, heart rate 120 beat per minute, respirations 24,
temperature 98.0 and documented on the electronic health record. The nurse and physician
promptly initiated the National Institutes of Health (NIH) Stroke Scale while implementing the
telemedicine technique of the Stroke Team Remote Evaluation using a Digital Observation
Camera (STRokE DOC) (Demaerschalk, Rama, Ernstrom, & Meyer, 2012). This program allows
us to either initiate a drip and/or ship. A physician in the neurology department at the Mayo
Clinic, Phoenix, Arizona, performs an evaluation by camera. A stat noncontrast computed
tomography (CT) of the head was ordered. CT results reveal an ischemic left hemisphere infarct.
Recommendations from STRokE DOC to initiate thrombolytic therapy, a tissue plasminogen
activator (tPa) are immediately administered per STRokE DOC suggestion. Blood was
immediately drawn for Partial thromboplastin time (PTT), prothrombin time/international
normalized ratio (PT/INR), complete blood count (CBC), and complete metabolic panel (CMP).
A Foley catheter was inserted prior to tPa administration for accurate measurement of intake and
output. A total of three intravenous lines were implemented. Other orders included Cardiac echo,

TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

EEG, and Carotid ultrasound. The intensive care unit (ICU) was notified for possibility of CVA
patient transfer and care flight was notified as well of potential transfer to another facility.
History was obtained via family members and cell phone data. Medications included two
antihypertensive agents, lisinopril 40 mg per day, metoprolol XL100mg per day, Paxil 40 mg per
day, low dose hormone birth control pill, and an Epi pen. Patient is allergic to ace inhibitors,
Lidocaine, Morphine Sulfate, and multiple food products like milk, wheat and raw vegetables.
Family members report noncompliance with lifestyle risk factors as patient continues to smoke
and is physically inactive. Patients mother expresses concern about level of stress experienced
related to holidays and a demanding work schedule. It is noted the hours of sleep the patient is
getting nightly is between four to six hours. The patient works long hours during the day
estimating thirteen to sixteen hours three times a week. The department this patient works
requires her to take call twice a week.
Patient is not established with a primary care provider and is following peripherally with
a cardiologist from the workplace. The patient was counseled by her cardiologist concerning
weight loss, smoking cessation, and the possibility of stopping oral contraceptives because of the
cigarette smoking and uncontrolled hypertension (HTN).

Assessment Guidelines
1. General survey: The patient with a CVA will present with an altered general
appearance. Upon interview there is a noticeable change in orientation, LOC, and difficulty with
communication (Malik & Wechler, 2011). The nurse notes different facial expressions and the
inability to follow simple commands. The patients skin color may appear pallor or extreme
redness is visible (Malik & Wechler, 2011). The breathing pattern may be accelerated due to

TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

anxiety level or shallow because of severity of cerebral damage (Ball, Dains, Flynn, Soloman, &
Stewart, 2015). A severe headache from unknown origin needs to be noted (Ball et al., 2015).
2. Neurological: The NIH Stroke Scale assessment and STRokE DOC are to be implemented for
a patient with suspected CVA symptoms (Demaerschalk et al., 2012). Other assessment scales
that can be utilized are a modified Rankin Scale and the Barthel Index (Harrison, McArthur, &
Quinn, 2013). Questions of orientation to person, place, & time are asked. The patients mood,
affect, memory, judgment, & insight are inquired about (Malik & Wechler, 2011). Assessment of
cranial nerves II-XII and evaluation of extra ocular movements are performed (Malik & Wechler,
2011). Pupils are examined if they are equal and reactive to light and if there are any visual
disturbances (Malik & Wechler, 2011). The tongue and palate are examined, as well as the
patients motor, coordination, and gait (Ball et al., 2015). Nausea, vomiting, diplopia, and
pathological hiccups will need to be assessed to help determine the location of the cerebral
infarct (Go & Worman, 2016).
3. Cardiac/Vascular: Vital signs are obtained on the CVA patient, as HTN is a cause for many
adverse events. An ECG is obtained to evaluate, heart rate and rhythm, as many CVA victims are
in atrial fibrillation (Malik & Wechler, 2011). The heart sounds are auscultated for S1 and S2,
murmur, rub, or gallop (Ball et al., 2015). The care provider questions the patient about having
palpitation or chest pain (Ball et al., 2015). The patients pulses are palpated and carotid arteries
are auscultated for bruit, which many CVA patients are known to exhibit (Malik & Wechler,
2011).
4. Pulmonary: Auscultation of lung sounds is performed bilaterally (Go & Worman, 2016). The
assessment of respiratory pattern, shortness of breath, cough, wheezing, chest wall tenderness or

TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

deformity is to be completed (Malik & Wechler, 2011). Head of bed should be at 30 degrees to
help prevent aspiration and decrease the risk of intracranial pressure (Go & Worman, 2016).
5. Gastrointestinal: The abdomen is examined and palpated for softness/hardness, tenderness,
masses, or organomegaly (Malik & Wechler, 2011). Auscultation for bowel sounds to be
performed on all four quadrants and questions asked in regards to bowel movement pattern,
dysphagia, diarrhea, jaundice, vomiting, nausea, or anorexia (Ball et al., 2015).
6. Musculoskeletal: As the CVA patient usually demonstrates one-sided paralysis; the nurse
examines the patients extremities for myalgia, arthralgia, edema, weakness, or cramps (Go &
Worman, 2016). It is to be noted if the patient exhibits back pain, cyanosis, or edema (Malik &
Wechler, 2011).
7. Genitourinary: Interviewing the patient for answers are about the patients urinary frequency,
dysuria, incontinence, color and odor are obtained by the nurse (Malik & Wechler, 2011).
8. Integumentary: Many CVA victims are dehydrated and the skin color, texture, turgor, rash,
lesion, pruritus, teeth, and oral mucosa are to be evaluated for the need of rehydration (Malik &
Wechler, 2011).
9. Symptom Assessment: CVA patients most commonly present with one-sided facial drooping
or palsy, one-sided arm/leg weakness or paralysis and need evaluation as such (Go & Worman,
2016). Difficulty communicating, such as aphasia, slurred speech, and confusion needs to be
assessed by the healthcare provider (Malik & Wechler, 2011). A severe headache of unknown
cause, vision changes, coordination/balance problems, sensory and memory loss are included as
symptoms of a neurological event and must be evaluated and recognized by the nurse (Malik &
Wechler, 2011). Glucose management will need to be monitored status post CVA related to the
trauma to the cerebral tissue (Go & Worman, 2016).

TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

Holistic Assessment
Patient is going to require further evaluation on psychological, social, and spirituals
needs (Creutzfeldt, Holloway, & Walker, 2012). Anxiety and/or depression are common at some
point following a cerebral vascular accident associated with the presence of cognitive deficits,
behavioral changes, emotional changes, and personality changes (Cumming, Blomstrand, Skoog,
& Lindin, 2015). It is imperative to assess for psychological distress, well-being, quality of life,
level of disability, financial status, relationship status, and home environment (Creutzfeldt et al.,
2012). A quality of life (QOL) assessment tool should be utilized at this time to measure thirteen
factors that can interrupt the CVAs survivors recovery (Harrison et al., 2013). Spiritual
resilience following the aftermath of a CVA varies among the individual. Spirituality needs to be
addressed by considering different cultures and religious traditions (CreutzfeldtR et al., 2012).
The expertise of a spiritual care provider or chaplain will aid with the patients holistic
assessment (CreutzfeldtR et al., 2012). By utilizing the spiritual caregivers, they can provide
professional and sound recommendations.
Health Promotion Factors
Key risk factors include age, gender, ethnicity, family history, previous CVA, transient
ischemic attack (TIA), patent foramen ovale (PFO), and fibromuscular dysplasia (FMD)
(Kanekar, Zacharia, & Roller, 2012). Hypertension, atherosclerosis, dyslipidemia, atrial
fibrillation, diabetes mellitus, circulatory problems, and carotid artery stenosis are primary
medical pathologies and daily living risk factors include poor eating habits, obesity, physical
inactivity, smoking, and excess alcohol intake (Ball et al., 2015). Stroke is not common among
people under the age of 40 but there are more cases documented related to sedentary lifestyles

TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

(Ball et al., 2015). Health promotion can help prevent devastating strokes from occurring and
support wellness.
Reducing risk factors and living a healthy lifestyle is a primary prevention for a CVA.
With the help community outreach programs and counseling about stroke prevention will
decrease the amount of cases recorded. Counseling with healthcare professionals and local
fitness clubs can help decrease the risk associated with CVA. Becoming physically fit,
nutritionally responsible, abstinence of smoking, medication compliance, decreasing stress
factors, proper rest, and developing inner peace, will all promote health and wellness.
Summary of Assessment Findings
Right-sided facial drooping, right-sided arm and leg weakness, slurred speech, severe
headache, and hypertension (HTN) are all findings indicating a CVA has occurred. Interruption
of cerebral blood flow due to a thrombus in the left hemisphere creates cellular demise affecting
the opposite side of the body and aphasia. The lack of blood flow to the left frontal and temporal
lobes will result with these right-sided deficits. An abrupt severe headache with unknown origin
is an indicator of a CVA (Kanekar, Zacharia, & Roller, 2012). With prolonged uncontrolled HTN,
vessels can develop atherosclerosis leading to thrombus formation and an increased for a CVA
(Kanekar et al., 2012). In this patient-based case study, the nursing assessment and diagnostic
findings are conclusive of an ischemic cerebral injury.
Here is the link to the assessment video: https://youtu.be/C9MqtMMjfyc

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TYPICAL PATIENT CASE AND COMPREHENSIVE GUIDE

References
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Creutzfeldt, C. J., Holloway, R. G., & Walker, M. (2012). Symptomatic and palliative care for
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