Nursing assessments
Vital signs: blood pressure, heart rate/rhythm, respiratory rate, temperature, oxygen saturation.
Respiratory assessment: rate, work of breathing, use of accessory muscles, auscultation for crackles/rales, wheezes, or decreased breath sounds; presence of orthopnea or paroxysmal nocturnal dyspnea.
Cardiac assessment: heart sounds (S3, S4), murmurs, peripheral pulses, capillary refill.
Volume status: jugular venous distension, peripheral edema (location and pitting), daily weights, abdominal distension (ascites).
Fluid balance: accurate intake and output monitoring, urine output trends, frequency.
Perfusion and end-organ function: mental status, skin temperature and color, urine output, peripheral perfusion.
Laboratory and diagnostic review: BNP/NT-proBNP trends, electrolytes (K+, Na+), renal function (BUN, creatinine), liver tests, chest x-ray, ECG, arterial blood gases if indicated.
Medication reconciliation and adherence: current meds, recent changes, diuretics, ACE inhibitors/ARBs, beta-blockers, other HF meds.
Activity tolerance: exercise capacity, fatigue level, tolerance of ADLs, need for rest periods.
Psychosocial and education needs: understanding of condition, support system, ability to follow diet and fluid restrictions, access to resources.
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