Conversely, injection forms, though being painful and needing help of medical personnel for application, help to quickly achieve necessary concentration of preparation in blood doxycycline online Antibiotic is usually chosen in an empiric way (at random). But when choosing one is obligatory guided by definite rules.

Assessment of patients who present with signs and symptoms suggestive of new onset heart failure or
exacerbation of chronic heart failure requires a comprehensive approach as outlined on these cards. Use
your “cash” card to insure appropriate assessment of all patients.

- Coronary artery disease
- Excessive dietary sodium intake
antidysrhythmics (Vaughn Williams Class I) SIgNS OF HEART FAILURE:
- Tachycardia
- Third heart sound (S3)
- Increased jugular venous pressure
- Positive hepatojugular reflux
- Bilateral crackles
- Peripheral edema not due to venous insufficiency
- Laterally displaced apical impulse
- Weight gain
- Abdominal distention (Note: These signs are generally associated with congestion; not all
patients with acute heart failure are congested).
- Dyspnea on exertion
- Dyspnea at rest
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Fatigue
- Decreased exercise tolerance
- Unexplained cough, especially at night
- Acute confusion or delirium
- Abdominal or gastrointestinal symptoms (e.g. nausea, bloating, abdominal pain, anorexia)
- Decreased food intake
- Decline in functional status
- Complete blood count
- Urinalysis
- Serum electrolytes including calcium and magnesium
- Blood urea nitrogen
- Serum creatinine
- B-type natriuretic peptide
- Fasting lipid panel
- Fasting blood glucose - Liver function tests - Drug levels of relevant medications (e.g., digoxin) - Thyroid panel - 1-lead electrocardiogram - Chest radiograph - Two-dimensional echocardiography - Radionuclide imaging (consider) - Cardiopulmonary exercise testing (consider) - Cardiac catheterization (consider) - Myocardial biopsy for suspected myocarditis (consider) ASSESSmENT QUESTIONS:
• What symptoms prompted you to seek medical care? When did they begin?
• Did your symptoms begin suddenly or gradually worsen over time?
• What makes the symptoms better/worse?
• Do the symptoms occur continuously or only with certain activities?
• Do symptoms improve with rest?
• Do you have any pain now? Did you recently have pain? Rate on a 0-10 scale.
• Has your heartbeat felt any different than usual? E.g., “race,” “flutter,” or “skip?”
• Have you felt short of breath? Do you wake up short of breath at night?
• Can you speak as much as you like before getting short of breath?
• What makes your breathing easier?
• Do you cough? Is it worse than usual?
• Do you cough throughout the day or mostly in the morning?
• Do you cough up any secretions?
• Do you use oxygen at home?
• Have symptoms kept you from sleeping?
• Do you sleep in bed or in a chair?
• Are you able to lie flat in bed?
• How many pillows do you use to sleep? Is this more or less than usual? • Have you recently slept more or less than usual? Do you feel rested?• Ask spouse/significant other if patient snores or intermittently stops breathing during sleep.
• Have you recently eaten more salty foods or drank more water than usual?
• How often do you eat out?
• How often do you weigh yourself?
• Have you gained or lost weight recently?
• Have you experienced any swelling? Is swelling present all day or only evenings?
• How far up your legs do you have edema?
• Have you felt bloated or had edema?
• Are your clothes, belt, rings, and shoes tighter than 1 week or 1 month ago?
• Have you had nausea or abdominal pain?
• Have you taken all prescribed meds?
• Did you run out of any medications?
• Have you had diarrhea/vomiting that may have affected absorption of medications?
• Have you taken extra diuretic meds?
• Have you changed the dose of any med?
• Did any physician/NP recently prescribe different medications for you or change the dose
• Do you take any over-the-counter medications or herbal supplements? Activity
• How far can you walk?
• Can you dress, bathe, prepare food, climb stairs without stopping to rest?
• What activities could you do recently but not now because of worsened symptoms?
• Have you decreased your activity level?
• Do you have difficulty remembering information or feelings of confusion?
• Have you had other health problems that may make your heart failure worse?
2006 American Association of Heart Failure Nurses


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