Assessment of the cardiac status

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?
  6. Apa format required
  7. Reference:Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders. 
    • Chapter 18: Thorax and Lungs
      • pp. 413–441 (Structure, Function, The Thoracic Cavity, Developmental Competence, Subjective Data, Objective Data)
    • Chapter 19: Heart and Neck Vessels
      • pp. 459–492 (Structure and Function, Heart Wall, Chambers, and Valves, Heart Sounds, Developmental Competence, Subjective Data, Objective Data )
    • Chapter 20: Peripheral Vascular System and Lymphatic System
      • pp. 509–529 (Structure and Function, Lymphatics, Developmental Competence, Subjective Data, Objective Data)

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