Nursing Assessments

Listed below are relevant and important nursing assessment the nurse performs to provide sound care to the patient with heart failure.

Physical Assessment:

  • Vital signs
    • Heart rate
    • Blood pressure
    • Respiratory rate
    • Oxygen saturation
  • Daily weight (first thing in the morning, before breakfast and after voiding)
  • Auscultate the lungs
  • Apical pulse
  • Urine output
    • Oliguria
    • Nocturia
  • Mental status
    • Orientation to person, place, time, situation
  • Auscultate the heart tones
    • S3 and S4 heart tones may be present if in acute exacerbation
  • Jugular vein distention
  • Hepatomegaly
  • Dependent edema
    • ***Unreliable sign of heart failure***
  • Nutritional intake, fluid intake

Psychosocial Assessment

  • Depression
  • Support

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