CVS case study

Topics: Heart, Blood, Lung Pages: 3 (537 words) Published: October 10, 2014
West Virginia University at Parkersburg
Nursing 131 – Physical Assessment

Case Study – Cardiovascular Disease

Nancy Riverhawk 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 1 month ago, getting worse
Relieved with rest, exacerbated with activity
Denies pain chest
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, aspirin 325 mg per day

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

Is the fatigue constant or intermittent- to determine what cause could be acute vs. chronic Is there a simple reason for the fatigue-such as boredom, extra activity, no sleep, etc.… What is the quality of your sleep?

Have you had any recent illnesses or change in medications OTC or prescribed? Any new stressors in your life? - Such as family/health /financial/emotional/physical etc.. What does your diet consist of on a daily basis, is this new? - Also does it include alcohol/caffeine/smoking if so how much?

2. What other assessments would be for this patient?

Full head to toe neuro/skin/lungs/heart/pulses/skin turgor/percussion/BP/temp, etc.… Maybe some tests such as; ECG, EKG, stress test, sleep test/observation, etc.… Lab tests such as CBC w/ diff, TSH, LFP, cholesterol, A1C, serum glucose, fasting glucose, U/A, CMP, B12, ECT… Review of medications, past medical history, vaccination records, environmental factors, family history Assessment of other current problems or symptoms.

Weight

3. What are some causes of fatigue?

Thrombocytopenia, anemia, thyroid dysfunctions, auto-immune, DM, fibromyalgia, osteoporosis, medications,...
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