Question

Part 2

S.P. is a 75-year-old female 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

What other questions should the nurse ask about the fatigue?

What other assessments are necessary for this patient?

What are some causes of fatigue?

Develop a problems list from the objective and subjective data.

What should be included in the plan of care?

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

Answer 1

These are questions that should be asked by the nurse about fatigue:

-Do you experience any other symptoms along with fatigue?

-how long do you sleep and what are you sleeping habits?

-what is your day today life style?

-do you feel sad depressed along with feeling fatigued?

-what sort of food do you take daily?

Other assessment necessary for the patient are:

Physical examinations for lymphadenopathy ,goiter ,cardiac murmur ,neurological abnormality. Total blood count, erythrocyte sedimentation rate ,chemistry panel ,thyroid function test, pregnancy test if indicated and urine analysis, fluid intake and output.

Some causes of fatigue are:

Mental disorders like depression, eating disorder can cause fatigue. Anaemia ,diabetes, chronic fatigue syndrome, cancer ,certain medication ,lack of sleep ,emotional stress,physical exertion obesity ,grief.

List of problems from the objective and subjective data:

Nephrotic syndrome,coronary artery disease ,peripheral vascular disease, left ventricular hypertrophy, congestive cardiac failure.

Plan of care:

-as a treatment of fatigue promote regular physical exercise.

-a good sleep at least 48 hours a day.

-salt in your diet.

-include foods with less amount of fat in your diet .

-manage stress

-improve nutritional status and evaluate the the fluid intake and output.

-maintain ECG monitoring

-monitor the blood pressure and heart beat every 5 minute during the attack.

Cause of fatigue for this patient-may be congestive cardiac failure.