S.P. is a 75-year-old woman who presents to the provider's office with fatigue. Subjective Data PMH: HTN, hyperlipidemia, MI 3 years ago Fatigue started about a month ago, getting worse Relieved with...


S.P. is a 75-year-old woman who presents to the provider's office with fatigue.




Subjective Data


PMH: HTN, hyperlipidemia, MI 3 years ago


Fatigue started about a month ago, getting worse


Relieved with rest, exacerbated with activity


Denies chest pain


Ankles swollen




Objective Data


Vital signs: T 37 P 112 R 18 BP 110/54


Lungs: bilateral lower lobe crackles


O2 Sat = 94%


Skin = cool to touch


CV = heart rate regular, positive peripheral pulses, ECG = no changes


+2 edema bilateral ankles


Medications: Metoprolol 20 mg per day, 325 mg of aspirin per day




Questions



  1. What other questions should the nurse ask about the fatigue?

  2. What other assessments are necessary for this patient?

  3. What are some causes of fatigue?

  4. Develop a problems list from the objective and subjective data.

  5. What should be included in the plan of care?

  6. Based on the readings, what is the most likely cause of fatigue for this patient?



Jun 07, 2022
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