NURSING CASE STUDY
Heart Failure / Cardiac
58-Year-Old Patient: Robert Mitchell
Framework: ADPIE — Assess | Diagnose | Plan | Implement | Evaluate
Grade: A+ | 19 Pages | 2026/2027 Edition
Includes: Complete Assessment, NANDA Diagnoses, Care Plan,
Clinical Reasoning Q&A with Rationales, Evidence-Based Interventions
,Table of Contents
1. Patient Overview & Scenario ........ Page 3
2. Medical & Social History ........ Page 4
3. ADPIE Framework Overview ........ Page 5
4. A — Assessment ........ Page 6
4.1 Vital Signs & General Appearance ........ Page 6
4.2 Head-to-Toe Physical Assessment ........ Page 7
4.3 Diagnostic Data: Labs, ECG & Imaging ........ Page 8
5. D — Nursing Diagnoses (NANDA) ........ Page 9
6. P — Planning: Goals & Outcomes ........ Page 11
7. I — Implementation: Nursing Interventions ........ Page 13
8. E — Evaluation ........ Page 15
9. Clinical Reasoning Questions & Answers ........ Page 16
10. References ........ Page 19
, 1. Patient Overview & Scenario
Clinical Setting: Emergency Department → Medical-Surgical Unit, City General Hospital
Case Author: RN, BSN — Advanced Clinical Nursing Practice, 2026/2027 Edition
Patient Profile
Full Name Robert Mitchell
Age 58 years
Sex Male
Race/Ethnicity African American
Weight 102 kg (BMI 33.2 — Obese Class I)
Height 175 cm
Marital Status Married, two adult children
Occupation Retired truck driver
Insurance Medicare with supplemental coverage
Allergies Penicillin (rash); Ibuprofen (fluid retention)
Code Status Full Code
Admitting Diagnosis Acute Decompensated Heart Failure (ADHF) with Reduced Ejection Fraction
Clinical Scenario
Mr. Robert Mitchell is a 58-year-old African American male brought to the Emergency Department by
ambulance after his wife called 911 when he became acutely short of breath while sitting in his recliner
watching television. She reports he has been progressively more short of breath over the past five days
and has gained approximately 8 pounds in one week. He has been sleeping in his recliner for the past
three nights because he cannot breathe lying flat.
On arrival, Mr. Mitchell is visibly distressed, diaphoretic, and using accessory muscles to breathe. He is
sitting upright and says: "I can't catch my breath — my legs look like tree trunks." He is alert and
Heart Failure / Cardiac
58-Year-Old Patient: Robert Mitchell
Framework: ADPIE — Assess | Diagnose | Plan | Implement | Evaluate
Grade: A+ | 19 Pages | 2026/2027 Edition
Includes: Complete Assessment, NANDA Diagnoses, Care Plan,
Clinical Reasoning Q&A with Rationales, Evidence-Based Interventions
,Table of Contents
1. Patient Overview & Scenario ........ Page 3
2. Medical & Social History ........ Page 4
3. ADPIE Framework Overview ........ Page 5
4. A — Assessment ........ Page 6
4.1 Vital Signs & General Appearance ........ Page 6
4.2 Head-to-Toe Physical Assessment ........ Page 7
4.3 Diagnostic Data: Labs, ECG & Imaging ........ Page 8
5. D — Nursing Diagnoses (NANDA) ........ Page 9
6. P — Planning: Goals & Outcomes ........ Page 11
7. I — Implementation: Nursing Interventions ........ Page 13
8. E — Evaluation ........ Page 15
9. Clinical Reasoning Questions & Answers ........ Page 16
10. References ........ Page 19
, 1. Patient Overview & Scenario
Clinical Setting: Emergency Department → Medical-Surgical Unit, City General Hospital
Case Author: RN, BSN — Advanced Clinical Nursing Practice, 2026/2027 Edition
Patient Profile
Full Name Robert Mitchell
Age 58 years
Sex Male
Race/Ethnicity African American
Weight 102 kg (BMI 33.2 — Obese Class I)
Height 175 cm
Marital Status Married, two adult children
Occupation Retired truck driver
Insurance Medicare with supplemental coverage
Allergies Penicillin (rash); Ibuprofen (fluid retention)
Code Status Full Code
Admitting Diagnosis Acute Decompensated Heart Failure (ADHF) with Reduced Ejection Fraction
Clinical Scenario
Mr. Robert Mitchell is a 58-year-old African American male brought to the Emergency Department by
ambulance after his wife called 911 when he became acutely short of breath while sitting in his recliner
watching television. She reports he has been progressively more short of breath over the past five days
and has gained approximately 8 pounds in one week. He has been sleeping in his recliner for the past
three nights because he cannot breathe lying flat.
On arrival, Mr. Mitchell is visibly distressed, diaphoretic, and using accessory muscles to breathe. He is
sitting upright and says: "I can't catch my breath — my legs look like tree trunks." He is alert and
