Here’s a fictional patient case study that provides enough detail for you to fill out both the
“Problem-Based Care Plan Worksheet” and the “Care Plan”:
Fake Patient Case Study: Maria S.
Client’s Initials: M.S.
Age: 68
Sex: Female
Language: Spanish and English
Admission Date: 05/15/2025
Allergies: Penicillin (rash and shortness of breath)
Admitting Diagnosis:
Congestive Heart Failure (CHF) exacerbation
Past Medical/Surgical History:
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Hypertension (HTN)
Type 2 Diabetes Mellitus
Hyperlipidemia
Coronary Artery Disease (CAD)
Cholecystectomy (2012)
History of Present Illness / Chief Complaint:
Maria S. was admitted with worsening shortness of breath, orthopnea, and bilateral lower
extremity swelling over the past 4 days. She states she has gained 5 pounds in the past week and
feels “exhausted walking just to the bathroom.” She reports poor appetite and a dry cough.
Denies chest pain.
Recent Procedures:
Chest X-ray
Echocardiogram
BNP Blood Test
Diagnostic Tests & Labs Ordered:
Labs:
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BNP: 780 pg/mL (↑)
Na+: 132 mEq/L (↓)
K+: 4.8 mEq/L
Creatinine: 1.6 mg/dL (↑)
Glucose: 168 mg/dL (↑)
WBC: 8,700 /mm³
Hgb: 12.5 g/dL
Hct: 39%
Platelets: 220,000 /mm³
Diagnostics:
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Chest X-ray: Pulmonary congestion and cardiomegaly
ECG: Sinus rhythm with occasional PVCs
Echocardiogram: Ejection fraction 35%
Medications Taken Prior to Admission:
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Lisinopril 10 mg daily
Furosemide 20 mg daily
Metformin 500 mg BID
Atorvastatin 40 mg daily
Aspirin 81 mg daily
Current Scheduled Medications:
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Furosemide 40 mg IV BID
Lisinopril 10 mg PO daily
Metoprolol 25 mg PO BID
Insulin sliding scale
Potassium Chloride 20 mEq PO daily
PRN Medications:
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Acetaminophen 650 mg PO q6h PRN for pain or fever
Assessment Findings:
Vital Signs #1:
T: 98.4°F, HR: 102 bpm, RR: 22, BP: 150/90, SpO2: 91% RA
Pain: 2/10 (mild muscle aches)
Vital Signs #2 (evening):
T: 98.6°F, HR: 98 bpm, RR: 20, BP: 145/88, SpO2: 94% on 2L NC
24 HR Intake: 1200 mL
24 HR Output: 2200 mL (on diuretics)
IV Access: 20G in left forearm
Urine Method: Foley catheter
Diet: Cardiac, low sodium, diabetic diet
Last BM: 2 days ago
DVT Protocol: SCDs and ambulation assistance
Skin Protocol: Daily skin checks and barrier cream to sacrum
Physical Assessment:
Neurological/Mental: Alert, oriented x3, slightly anxious
HEENT: Mucous membranes dry, slight periorbital puffiness
Lungs: Crackles in bilateral lower lobes
Cardiovascular: S1/S2 audible, irregular rhythm, mild systolic murmur
Peripheral Vascular: 2+ pitting edema bilateral ankles
Gastrointestinal: Hypoactive bowel sounds, soft, nontender
Genitourinary: Clear yellow urine via Foley
Musculoskeletal: Generalized weakness, walks with assistance
Integumentary: No open wounds, skin warm, dry, some sacral redness
Assistive Devices: Dentures, glasses, hearing aids
Disease Process: CHF
Client Comparison:
Maria fits the typical CHF profile: elderly, female, history of HTN and CAD, ejection fraction <
40%, presenting with dyspnea, edema, and fatigue.
Treatment Match:
Treatment includes diuretics, ACE inhibitors, beta-blockers, fluid/sodium restriction, and cardiac
diet.
Applicable Nursing Diagnoses:
1. Excess fluid volume related to decreased cardiac output as evidenced by bilateral edema,
weight gain, and crackles.
2. Impaired gas exchange related to pulmonary edema as evidenced by crackles, dyspnea,
and SpO2 of 91%.
3. Activity intolerance related to imbalance between oxygen supply/demand as evidenced
by fatigue and dyspnea on exertion.
4. Knowledge deficit related to disease management as evidenced by non-adherence to
fluid restriction and medication confusion.