week 5

Patient case study (fictional) for BSN students nearing graduation

Patient ID: MRN 000123456 (fictional) Name: Thomas Riley (Mr. Riley) Age: 68 Sex: Male DOB: 08/14/1957 Date of admission: 02/07/2026 Admission source: ED from home via EMS Code status: Full Code Allergies: Penicillin (rash)

Presenting complaint: Progressive shortness of breath for 3 days, increased lower-extremity swelling, cough with white sputum, orthopnea (needs 3 pillows), decreased exercise tolerance.

Past medical history:

• Chronic heart failure with reduced ejection fraction (HFrEF), diagnosed 5 years ago (EF 30%)
• Coronary artery disease (stented 3 years ago)
• Hypertension
• Chronic obstructive pulmonary disease (COPD), emphysema-predominant
• Type 2 diabetes mellitus, diet-controlled
• Chronic kidney disease stage 3a (eGFR ~52 mL/min/1.73 m2)
• Hyperlipidemia
• Osteoarthritis of knees

Surgical history:

• CABG x1 (no), PCI with stent 3 years ago
• Left knee arthroscopy

Social history:

• Lives with wife in single-level home
• Retired factory worker
• Former smoker: 40 pack-year history, quit 5 years ago
• Alcohol: occasional wine
• No illicit drug use
• Support: spouse able to assist; adult daughter nearby

Home medications (prior to admission):

• Metoprolol succinate 100 mg PO daily
• Lisinopril 20 mg PO daily
• Furosemide 40 mg PO daily (often misses doses)
• Spironolactone 25 mg PO daily
• Atorvastatin 40 mg PO nightly
• Tiotropium inhaler 18 mcg daily
• Albuterol inhaler PRN (uses 23 times/day)
• Aspirin 81 mg PO daily
• Multivitamin

Allergies: Penicillin rash

Initial ED assessment / triage vitals:

• T: 99.1F (37.3C)
• HR: 110 bpm, regular
• BP: 160/92 mmHg
• RR: 26 breaths/min
• SpO2: 88% on room air, improves to 94% on 4 L/min nasal cannula
• Pain: 2/10 (chest tightness occasionally)

Physical exam (on admission):

• General: Alert, anxious, mild respiratory distress
• HEENT: No JVD at 30 degrees (note: JVD present when more upright)
• Lungs: Bilateral crackles at bases, decreased breath sounds with expiratory wheeze; mild use of accessory muscles
• Cardiac: Tachycardic, S1/S2, S3 present, no murmurs noted
• Abdomen: Soft, non-tender
• Extremities: Bilateral pitting edema to mid-shins, cool peripheries
• Neuro: Alert and oriented x3

Initial diagnostics:

• CXR: Cardiomegaly with pulmonary vascular congestion and bilateral interstitial/alveolar edema, small bilateral pleural effusions
• ECG: Sinus tachycardia, no acute ischemic changes
• BNP: 1,200 pg/mL (elevated)
• Troponin I: 0.02 ng/mL (normal)
• ABG on 4 L NC: pH 7.45, PaCO2 34 mmHg, PaO2 70 mmHg (mild hypoxemia)
• CBC: WBC 9.8 x10^9/L, Hgb 13.2 g/dL, Hct 39%, Plt 210 x10^9/L
• BMP: Na 132 mmol/L, K 4.8 mmol/L, Cl 98 mmol/L, HCO3 22 mmol/L, BUN 28 mg/dL, Creatinine 1.4 mg/dL (baseline 1.2), Glucose 150 mg/dL
• LFTs: within normal limits
• Echo (prior record): EF 30% (last year)
• Urinalysis: trace protein, otherwise unremarkable
• Sputum culture: sent (pending)

ED course and admitting diagnosis:

• Primary: Acute decompensated heart failure (HFrEF exacerbation), likely precipitated by missed diuretic doses and possible COPD exacerbation
• Secondary: COPD exacerbation, volume overload
• ED treatment: Supplemental oxygen, IV loop diuretic (furosemide 40 mg IV bolus), nebulized albuterol/ipratropium, started on scheduled IV furosemide infusion protocol pending response, placed on telemetry, continuous pulse oximetry.
• Admitted to telemetry/medical-surgical step-down unit under cardiology.

Hospital day 1 plan & orders (sample):

• Continue oxygen titrated to SpO2 92%
• Furosemide IV 40 mg bolus then 10 mg/hr infusion (adjust per urine output and daily weights)
• Metoprolol hold until euvolemic and HR <100; resume later per cardiology
• Continue lisinopril 20 mg PO daily (hold if creatinine rises >30% or K >5.5)
• Spironolactone hold while on IV diuresis
• Nebulized albuterol/ipratropium q6h PRN for wheeze
• VTE prophylaxis: sequential compression devices (consider LMWH once stable)
• Daily labs: BMP, BNP qAM
• Strict I&O, daily weight each AM
• Cardiology consult for HF management and medication titration
• Respiratory therapy for inhaler technique, nebulizer treatments, pulmonary toilet
• Diet: cardiac (2 g sodium), diabetic-consistent as needed
• Education: low-sodium diet, medication adherence, activity tolerance, when to call provider
• Discharge planning: assess home support, f/up with cardiology & primary care within 1 week, consider home health if needed

Nursing assessment data (ongoing):

• Urine output: first 6 hours after IV furosemide bolus: 800 mL; next 12 hours: 1,200 mL
• Weight: admission 95 kg; prior baseline 90 kg (weight gain 5 kg)
• Vitals (12 hours after admission): T 98.6F, HR 96, BP 138/84, RR 20, SpO2 93% on 2 L NC
• Breath sounds: crackles improved slightly; dyspnea decreased from moderate to mild
• Peripheral edema decreased to ankles (pitting 1+)
• Blood glucose: 160 mg/dL fasting
• BMP (12 hours): Na 130, K 4.6, Creatinine 1.45 mg/dL, BUN 30

Potential and actual nursing diagnoses (examples):

• Impaired gas exchange related to pulmonary edema and COPD exacerbation as evidenced by SpO2 88% on room air and bilateral crackles.
• Excess fluid volume related to compromised regulatory mechanism (heart failure) as evidenced by weight gain, peripheral edema, pulmonary congestion, BNP elevated.
• Activity intolerance related to decreased cardiac output as evidenced by dyspnea on exertion and tachycardia with minimal activity.
• Risk for electrolyte imbalance related to diuretic therapy as evidenced by diuretic orders and borderline creatinine/BUN elevation.
• Deficient knowledge regarding disease process and medication adherence related to missed diuretic doses.

Nursing care plan interventions (examples with rationale and expected outcomes):

1. Oxygen therapy and respiratory support

• Intervention: Administer O2 to maintain SpO2 92%; monitor respiratory rate, work of breathing, ABGs.
• Rationale: Improve oxygenation, decrease work of breathing.
• Expected outcome: SpO2 92%, RR <22, decreased dyspnea.

1. Fluid removal and monitoring

• Intervention: Administer IV furosemide per order; monitor urine output hourly during infusion, record daily weights, assess mucous membranes and skin turgor, monitor electrolytes and renal function qAM.
• Rationale: Reduce volume overload, prevent renal impairment and electrolyte disturbances.
• Expected outcome: 0.51.0 kg weight loss/day initially, decreased edema, stable creatinine.

1. Prevention of complications

• Intervention: Telemetry monitoring for arrhythmias, fall risk precautions, VTE prophylaxis.
• Rationale: HF patients at risk for arrhythmias, falls, and thromboembolism.
• Expected outcome: No arrhythmias requiring emergent intervention, no falls, no DVT.

1. Medication management and reconciliation

• Intervention: Reconcile meds, clarify home diuretic adherence, educate on medication purposes and schedule, coordinate with pharmacy for discharge meds (ensure diuretic dosing and potassium monitoring).
• Rationale: Prevent readmission due to nonadherence and optimize HF regimen.
• Expected outcome: Patient verbalizes meds and doses, demonstrates inhaler technique.

1. Education and discharge planning

• Intervention: Teach low-sodium diet, daily weights, recognition of worsening HF signs (increased SOB, >23 lb overnight gain), when to seek care; arrange follow-up appointments; involve spouse in teaching.
• Rationale: Early recognition prevents readmission; caregiver involvement improves adherence.
• Expected outcome: Patient and spouse demonstrate understanding and plan for outpatient follow-up.

1. Mobility and activity progression

• Intervention: Encourage graded activity as tolerated, monitor vitals with ambulation, provide rest periods.
• Rationale: Prevent deconditioning while avoiding cardiac stress.
• Expected outcome: Activity tolerance improves, HR and BP within acceptable range during activity.

Progress notes example (Hospital day 2 morning):

• Subjective: Denies chest pain; reports breathing easier, requires 2 pillows at night now. States will try to take furosemide at home but sometimes forgets.
• Objective: Vitals stable, SpO2 94% on 2 L NC, RR 18, HR 86, BP 130/78. Lungs: decreased crackles. Urine output last 24 hrs: 2,400 mL. Weight 92 kg (down 3 kg from admission). BMP: Na 131, K 4.4, Creatinine 1.35 mg/dL.
• Assessment: Responding to diuresis; stable for step-down care. Needs med teaching and discharge planning.
• Plan: Continue diuretic per protocol, hold spironolactone until assessment by cardiology, schedule cardiology follow-up, begin discharge teaching, consider home diuretic supply and home health for initial medication reconciliation and weight monitoring.

Lab trends to monitor:

• Daily BMP (Na, K, Cr, BUN)
• BNP trends
• Weight and I&O
• Oxygenation and ABGs if indicated
• ECG/Telemetry for arrhythmias
• Sputum culture results (if infectious etiology suspected)

Discharge considerations (anticipated if stable by day 34):

• Transition IV diuretics to oral high-dose furosemide (e.g., 80 mg PO daily or as individualized) with clear instructions and pharmacy reconciliation
• Reinstate guideline-directed medical therapy (beta-blocker, ACE inhibitor) with cardiology input; titration outpatient
• Arrange cardiology appointment in 37 days
• Provide written and teach-back education: low-sodium diet, daily weights, medication schedule, inhaler technique, signs/symptoms requiring immediate care
• Consider home health for weight, vitals, medication reconciliation for first 12 weeks
• Provide referral to CHF clinic or heart failure management program

Student tasks / learning activities (for evaluation):

1. Perform focused cardiopulmonary assessment and document findings.
2. Calculate fluid balance for prior 24 hours and interpret significance.
3. Formulate 3 prioritized nursing diagnoses with supporting data.
4. Create a 24-hour nursing care plan with specific interventions, rationales, and measurable outcomes.
5. Demonstrate proper inhaler technique and teach-back with spouse.
6. Identify potential medication interactions/contraindications (e.g., ACE inhibitor + spironolactone with rising creatinine/K).
7. Develop discharge teaching checklist and complete a teach-back session (document results).
8. Recognize signs of worsening HF and when to escalate care.
9. Interpret BMP trend and suggest nursing actions for abnormal K or creatinine changes.
10. Communicate change-of-shift report including SBAR to receiving nurse.