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Cardio Case Study

S.P. is a 75-year-old woman who presents with fatigue that has worsened over the past month. On examination, she has a high pulse, crackles in her lungs, cool skin, and ankle edema. Given her history of hypertension, hyperlipidemia, and prior heart attack, along with findings on exam, the most likely cause of her fatigue is progressive heart failure exacerbated by her blood pressure medication.

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2K views

Cardio Case Study

S.P. is a 75-year-old woman who presents with fatigue that has worsened over the past month. On examination, she has a high pulse, crackles in her lungs, cool skin, and ankle edema. Given her history of hypertension, hyperlipidemia, and prior heart attack, along with findings on exam, the most likely cause of her fatigue is progressive heart failure exacerbated by her blood pressure medication.

Uploaded by

bbianca1990
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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IN CLASS CASE STUDY

S.P. is a 75-year-old woman who presents to the providers office with fatigue.

Subjective Data

PMH: HTN, hyperlipidemia, MI 3


years ago

Relieved with rest, exacerbated with


activity

Fatigue started about 1 month ago,


getting worse

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

1. What other questions should the nurse ask about the fatigue?
How long does it last when it occurs? Can you rate your fatigue 1 to 10? Is it
brought on by any specific activity or have you had any recent lifestyle changes?
Did it occur gradually or was it a sudden onset? Has the patient have been suffering
from sleep apnea? Is the patient a current smoker?
2. What other assessments would be necessary for this patient?
The nurse would check capillary refills on toes and fingers and auscultate the heart
as well as do a skin assessment and ask if the patients has felt any tingling or
numbness in her hands or feet. Diet is very important to ask since the patient is
diagnosed with hyperlipidemia. Assess the patient for anemia since the patient
suffers from cardiac disease that could be causing her fatigue. Assess intake and
output because the patient might be suffering from kidney dysfunction. Weigh the

patient to see if there is any major weight gain from last doctor visit because of the
retained fluid in the peripheral extremities.
3. What are some causes of fatigue?
One of the most common side effects of Metoprolol is weakness and fatigue. Also it
is very common with patient with heart failure to experience fatigue.
4. Develop a problem list from objective and subjective data.
OBJECTIVE DATA:
Pulse high
Bilateral Lung Crackles
Skin should be warm to touch not cool
+2 edema in bilateral ankles, which are not seen in a healthy adult
SUBJECTIVE:
Past medical history is concerning because she is more at risk for another MI
Swollen ankles
Fatigue started a month ago and is relieved with rest but exacerbated with activity.
5. What should be included in the plan of care?
Patient education on hypertension, pulmonary edema as well as change lifestyle so that
the patient can decrease symptoms of heart failure should be included in the plan of care.
Assess patients BUN/creatinine for renal failure. Advise patient to follow a low sodium
diet and to drink enough fluids. We must help patient find stressors that might trigger
symptoms and hopefully resolve them. A nurse should encourage gradual physical
activity to help promote a healthy lifestyle.
6. Based on the readings, what is the most likely cause of fatigue for this patient?
Progressive heart failure and possible side effect of the medication that they patient is
prescribed.

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