Case study 4 Guelda Josil ST. Thomas University Question 1: What other questions should the nurse ask about the fatigue? Does the patient currently smoke or work in an environment with smoke or dust? How long does the fatigue last, when it occurs, and rest is applied? At what time, are the fatigues frequently prone to occur? Have the patient experienced any sickness in the recent past? How is the patient’s appetite? Does the patient experience bilateral lung crackles? Question 2: What other assessments are necessary for this patient? The patient needs to have a hemoglobin test. Diet should be an important area of consideration based on the fact that the patient was diagnosed with hyperlipidemia Listening for any abnormal lung sounds; S3 could imply high amounts of fluids The healthcare provider can also investigate is the patient is anemic considering that the patient has suffered from cardiac ailments that could be resulting in the fatigue Conduct a CBC to determine if the patient is facing any type of fatigue Palpation of a carotid artery to check for apical impulse to try and identify any thrill. By doing this, the nurse would investigate refills on the patient’s fingers and toes and at the same time assess the skin to see if the patient feels numbness or tingling.
The nurse can also investigate the level of intakes against the output to establish if the patient could be suffering from kidney dysfunctionality. Question 3: what are some causes of fatigue? The fatigue can be caused by various reasons including lack of adequate sleep/sleep depriviation, poor nutrition. Poor blood flow, increased depression, stress levels, anxiety, Anemic and heart conditions. Question 4: Develop a problems list from the objective and subjective data Low oxygen saturation levels and increased pulse caused by the heart trying to compensate for oxygen inadequacy by pumping more oxygenated blood. Bilateral crackles may be an indication of increased fluids in lungs Edema ankles and the skin is cool.
Heart failure Question 5: What should be included in plan of care? The nurse should design a short term care plan for the patient to eliminate all possibilities of the patient fatigue as the nurse conducts further assessments to determine the root cause of the condition. The patient should be advised on issues relating to body weight and how to perform personal fluid retention weighting on a daily basis, same time. Based on the ankle problem, the nurse would educate the patient in elevating the ankles as a strategy to gravitate fluid to other parts of the body. The nurse should also educate the patient on energy conservation activities and how to avoid activities that might aggravate the fatigue problems or just avoiding activities likely to exacerbate the consumption of energy.
The nurse needs to educate the patient on diet, and some of the things to avoid like sodium due to sodium retention problems. The nurse can also recommend medication to help the patient with relaxation but while monitoring the effectiveness of the medication in resolving fatigue issues. Question 6: Based on the readings, what is the most likely cause of fatigue for this patient? Heart failure may be the most likely cause of fatigue in the patient. References Jarvis, C. (2015).
Physical examination and health assessment. Elsevier Health Sciences.
