1. Georgina Graves is a 42-year-old female who presents to the provider’s office with fatigue.
Subjective Data
- PMH: none, (except gynecological issues)
- Significant family history of heart disease
- Fatigue started about 2 months ago, getting worse
- Relieved with rest, exacerbated with activity
- Denies chest pain
- C/O shortness of breath on exertion
- Smoker 1 PPD
Objective Data
- Vital signs: T 37 P 100 R 18 BP 110/54
- Lungs: clear
- O2 Sat = 94%
- Skin = cool to touch
- CV = heart rate regular, positive peripheral pulses, ECG = intermittent complete left bundle branch block (New Finding)
- Edema
Medications: Premarin 0.3 mg po/day
- What other questions should the nurse ask about the fatigue?
- What other assessments would be necessary for this patient?
- What are some causes of fatigue?
- What should be included in the plan of care?
- Based on the readings, what is the most likely cause of fatigue for this patient?
2. Nelson Carson is a 62-year-old man who presents to his private practitioner’s office with a hacking, raspy cough.
Subjective Data
- PMH: HTN, CAD
- Cough is productive, bringing up green, thick phlegm
- Runny nose, sore throat
- No history of smoking or seasonal allergies
- Complains of fatigue
Objective Data
- Vital signs: T 37 P 72 R 14 BP 134/64
- Lungs: + Rhonchi bilateral upper lobes, wheezes
- O2 Sat = 98%
Medications: Metoprolol 25 mg per day, ASA 325 mg/daily
- What other questions should the nurse ask about the cough?
- What nursing diagnoses can be derived from the data?
- What should be included in the plan of care?
- What risk factors are associated with this age group?
- Based on the readings, what is the most likely cause of cough for this patient?
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