Week 5 Discussion – S.P. is a 75-year-old woman who presents
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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 the fatigue?
- What other assessments are necessary for this patient?
- What are some causes of fatigue?
- Develop a problem list from the objective and subjective data.
- What should be included in the plan of care?
- Based on the readings, what is this patient’s most likely cause of fatigue?
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