Blood pressure: appropriate cuff size, arm supported at heart level, patient seated with feet flat and back supported, after a 5-minute rest with no caffeine, nicotine, or exertion in the prior 30 minutes; document the arm and position; repeat after 1–2 minutes if elevated and record the average.
Heart rate: palpate the radial pulse 30–60 seconds; if irregular, auscultate the apical pulse for one full minute and note any apical–radial deficit.
Heart sounds: auscultate the aortic, pulmonic, Erb's, tricuspid, and mitral areas with the diaphragm and bell; position supine and in left lateral decubitus to bring out S3, S4, and low-pitched murmurs.
Jugular venous pressure: patient at 30–45° with the head turned slightly; measure the vertical height of the pulsation above the sternal angle.
Edema: press over a bony prominence (tibia, medial malleolus, dorsum of the foot) for about 5 seconds; grade 1+ to 4+ and note symmetry and the level reached.
Pulses: grade 0–4+ (0 absent, 1+ diminished, 2+ normal, 3+ increased, 4+ bounding); compare bilaterally and use Doppler if not palpable.
Capillary refill: compress the nail bed about 5 seconds and release; normal is under 3 seconds.
Orthostatic vitals: measure BP and HR supine after 5 minutes, then standing at 1 and 3 minutes; a drop of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic, or reproduction of symptoms, is positive.
Daily weight: same scale, same time of day, similar clothing; compare to the prior weight and to target/dry weight; thresholds commonly > 2–3 lb in a day or > 5 lb in a week.
