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Health assessment

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)
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
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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