Case study

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

1. What other questions should the nurse ask about the fatigue?

The nurse can ask the following questions about fatigue:

 When did it start?

 How long has it lasted?
 Is it something that comes and goes?
 Has it got worse over time?
 Does anything make it feel better or worse? For example, exercise, eating or pain.
 Does it affect your daily living activities such as washing, cooking or walking?
 Do you have any problems sleeping?
 Are you sleeping in the day and for how long?
 How long roughly do you sleep at night?
 Is it interrupted sleep, meaning do you get up or wake up during the night?
 Do you have any other symptoms with your fatigue such as feeling or being sick,
breathlessness or pain?
 Do you have any other medical conditions or symptoms?
 What medicines are you currently taking and when do you take them?
 Have you been sick lately?

2. What other assessments are necessary for this patient?

 Health history (biographical data ,souse of history ,reasons for seeking care, history of present
illness , past medical health history and family history)
 Complete physical examination head to toe assessment on the following areas/skills: -
 Vital Signs (pulse rate, respiration rate, temperature, oxygen saturation,
blood pressure, pain assessment) -
 Cranial Nerve examination
 Head assessment (hair, cranium, eyes, nose, mouth, ears, sinuses)
  Neck assessment (jugular vein, thyroid, trachea, carotid)
 Heart sounds assessment:
 Lung sounds assessment
 Abdominal assessment
 Assessing extremities (arms, hands, legs, feet)
 Back assessment
 Culture competency

Furthermore, the nurse can be focused on the following assessment based on the
subjective and objective data mentioned on this case:
 Jugular venous pressure to see if it's greater than 2cm when in semi-fowler to assess for fluid
overload.
 Auscultate for abnormal sounds; may hear pathologic S3 because of too much fluid  Palpate
the carotid artery;
 palpate for apical impulse to see if you can feel a thrill
 sedentary person may have decreased output which can cause fatigue

3. What are some causes of fatigue?

There are so many factors lead for fatigue can be:

1. Life style factors

For example (physical exertion, lack of physical activity, lack of sleep , being overweight
or obese , periods of emotional stress ,boredom ,grief ,using alcohol on a regular basis
,consuming too much caffeine and not eating a nutritious diet)
2. Physical health conditions:
For example (anemia .arthritis ,fibromyalgia ,chronic fatigue syndrome ,infections, such
as cold and flu ,Addison’s disease, a disorder that can affect your hormone
levels ,hypothyroidism, or underactive thyroid ,hyperthyroidism, or overactive thyroid ,sleep
disorders, such as insomnia ,eating disorders, such as anorexia ,autoimmune
disorders ,congestive heart failure ,cancer , diabetes ,kidney disease ,liver disease ,chronic
obstructive pulmonary disease (COPD) and emphysema )
3. Mental health conditions:
Such as (anxiety and depression)

4. Develop a problems list from the objective and subjective data.

 Subjective data :
 HTN
 Hyperlipidemia
 MI
 Fatigue
 Ankle swollen
 Objectives data:
 Low oxygen saturation and high pulse to try pumping more oxygenated blood to

compensate
 Bilateral crackles indicated fluid in lungs
  Skin is cool
 Edemas ankles

5. What should be included in the plan of care?

 Educating the patient on weight and how to weight because of the fluid retention. –
weight themselves on same time each day in b-day suit.
 Education on elevating the ankles to gravitate the fluid back into body.
 Educate on diet with sodium because of sodium retention with fluid restrictions.
 Energy conservation activities; which activities exacerbate the pt. too much.
 Educate the patient how to monitor intake and output.

6. Based on the readings, what is the most likely cause of fatigue for this patient?

Based on clinical manifestation demonstrated above the most likely cause of fatigue is heart
failure due to low cardiac output.