PLEASE RESPOND TO THE FOLLOWING CLASSMATE’S POST IN 50 WORDS OR MORE:
Option 2
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
What other questions should the nurse ask about her fatigue?
Is your fatigue associated with any shortness of breath (SOB)?
How has it affected your activities of daily living (ADL’S)?
How has your fatigue affected your appetite?
How has your fatigue affected your sleep?
2) What other assessments are necessary for this patient?
Additional questions that the nurse should ask S.P. include,
Have you experienced any orthopnea? (SOB while lying flat and relieved when sitting up)
Have you experienced any palpitations with or without lightheadedness?
Chest x-ray- to assess for pulmonary edema/vascular congestion
Labs- Troponin, CBC, CMP, BNP, Liver function test, blood urea nitrogen.
Echocardiogram- to determine ventricular function and hemodynamics.
3) What are some causes of fatigue?
Congestive Heart failure (CHF)
Hypoglycemia
Respiratory virus
Lack of sleep
Poor oral intake of required nutrients
4) Develop a problem list from the objective and subjective data.
S.P. is presenting with symptoms that are consistent with CHF. Symptoms of heart failure include those related to excess fluid accumulation and reduced cardiac function.
S.P. presents with +2 edema bilateral ankles, fatigue relieved with rest and exacerbated with activity, bilateral lower lobe crackles, and increased heart rate (HR 112).
Other symptoms of HF may include dyspnea, orthopnea, pain from hepatic congestion, abdominal distention from ascites.
5) What should be included in the plan of care?
Getting orders to diuretics if applicable
Relieving signs and symptoms of fluid overload
Teaching patient about dietary restrictions
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