Question
In: Nursing
S.P is a 75-year-old female who presents to the provider’s office with fatigue. Subjective Data PMH:...
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?
Part 3
Solutions
Nightingale answered 1 year agoRelated Solutions
S.P. is a 75-year-old female who presents to the provider’s office with fatigue. Subjective Data PMH:...
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...
Part 2 S.P. is a 75-year-old female who presents to the provider’s office with fatigue. Subjective...
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...
Part 2 M.A. is a 75-year-old female who presents to the provider’s office with fatigue. Subjective...
Part 2
M.A. 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...
Part 2 S.P. is a 3-year-old female toddler who presents to the pediatrician’s office for a...
Part 2
S.P. is a 3-year-old female toddler who presents to the
pediatrician’s office for a yearly well visit. The child complains
that her leg hurts.
Subjective Data
PMH of otitis media
Immunizations: Up to date
No medications
No allergies
Pain: 3/5 on pain scale
Attends preschool
Unable to recall injuring leg
Objective Data
Vital signs: T 98.3, P 92, R 18, BP 100/70
Lungs: clear in all fields
Heart rate and rhythm regular
Moving all extremities
+ Range of...
S.P. is a 3-year-old female toddler who presents to the pediatrician’s office for a yearly well...
S.P. is a 3-year-old female toddler who presents to
the pediatrician’s office for a yearly well visit. The child
complains that her leg hurts.
Subjective Data
PMH of otitis media
Immunizations: Up to date
No medications
No allergies
Pain: 3/5 on pain scale
Attends preschool
Unable to recall injuring leg
Objective Data
Vital signs: T 98.3, P 92, R 18, BP 100/70
Lungs: clear in all fields
Heart rate and rhythm regular
Moving all extremities
+ Range of motion legs...
C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter...
C.M. is an 89-year-old female who presents with her
daughter to the provider’s office. The daughter is concerned
because her mother has not been eating well.
Subjective Data
PMH: HTN, Hypothyroid
24-hour diet recall reveals approximately 1,100-calorie
intake
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data
Vital signs: T 37 P 72 R 12 BP 104/64
Weight: 105 lb
Weight last visit, 3 months ago: 115 lb
HT: 5 feet, 1 inch
Medications:...
C.M. is an 89-year-old female who presents with her daughter to the provider’s office. The daughter...
C.M. is an 89-year-old female who presents with her daughter to
the provider’s office. The daughter is concerned because her mother
has not been eating well.
Subjective Data
PMH: HTN, Hypothyroid
24-hour diet recall reveals approximately 1,100-calorie
intake
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data
Vital signs: T 37 P 72 R 12 BP 104/64
Weight: 105 lb
Weight last visit, 3 months ago: 115 lb
HT: 5 feet, 1 inch
Medications:...
Part 1 C.M. is an 89-year-old female who presents with her daughter to the provider’s office....
Part 1
C.M. is an 89-year-old female who presents with her daughter
to the provider’s office. The daughter is concerned because her
mother has not been eating well.
Subjective Data
PMH: HTN, Hypothyroid
24-hour diet recall reveals approximately 1,100-calorie
intake
Lives alone, daughter nearby
Does not drive
Daughter shops
Patient cooks light meals
Objective Data
Vital signs: T 37 P 72 R 12 BP 104/64
Weight: 105 lb
Weight last visit, 3 months ago: 115 lb
HT: 5 feet, 1...
Mike is a 69-year-old man who presents to the outpatient office with a cough. Subjective Data...
Mike is a 69-year-old man who presents to the outpatient office
with a cough.
Subjective Data
PMH: HTN, DM Cough is productive, bringing up green phlegm
Runny nose, sore throat
Denies fever
Sore throat pain when swallowing
No history of smoking or seasonal allergies
Objective Data
Vital signs: T 37, P 72, R 14, BP 134/64
Lungs: + Rhonchi bilateral upper lobes
O2 sat: 98%
Ears: TM bulging Nose: + erythema, yellow discharge
Throat: + erythema, pustules
Medications: metoprolol 12.5...
J.P. is a 50-year-old man who presents to the gastroenterologist with cramping and diarrhea. Subjective Data...
J.P. is a 50-year-old man who presents to the gastroenterologist
with cramping and diarrhea. Subjective Data Pain level is a 6/10
location = right and left lower abdomen Works as a union
construction worker, has missed 1 day of work States he has been
going to the bathroom about 8 to 10 times a day for past 2 days
Appetite is decreased PMH: Crohn’s disease, depression, anxiety
Objective Data Vital signs: T 37 P 80 R 14 BP 120/68 Bowel...
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