Clinical Make-up

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Clinical Make-up

Ticket for Clinical Make-up.  Please complete the following assignment as part of the clinical make up. You will complete this assignment bring it with you to your make-up day. If you do not complete the assignment you can not attend clinical make up , it will be considered an unexcused absence.

Define the following words:

Cardiac Cycle

Carotid Bruit

Orthostatic hypotension

Hypercapnia

Orthopnea

Apgar scoring system

Seizure

Syncope

Spinal nerves

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?
  2. What other assessments are necessary for this patient?
  3. What are some causes of fatigue?
  4. Develop a problems list from the objective and subjective data.
  5. What should be included in the plan of care?
  6. Based on the readings, what is the most likely cause of fatigue for this patient?