Case Study

    S.P. is a 75-year-old woman who presents to the providers 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

    Writing Prompts

    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?

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