Health assessment

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

1. What other questions should the nurse ask about the fatigue?
2. What other assessments would be necessary for this patient?
3. What are some causes of fatigue?
4. What should be included in the plan of care?
5. 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

1. What other questions should the nurse ask about the cough?
2. What nursing diagnoses can be derived from the data?
3. What should be included in the plan of care?
4. What risk factors are associated with this age group?
5. Based on the readings, what is the most likely cause of cough for this patient?