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SN arrived at patient residence and performed a skilled assessment of patient with a primary diagnosis of congestive heart failure. Vital signs obtained: BP 148/86, HR 96, SpO2 93% on 2 liters supplemental oxygen via nasal cannula. Cardiopulmonary assessment revealed crackles auscultated in the bilateral lung bases and +2 pitting edema to the bilateral lower extremities, increased from the previous visit. Weight obtained is 4 pounds above the last documented weight, consistent with fluid retention. Patient reports that shoes feel tight and that patient now requires two pillows to sleep comfortably, indicating worsening orthopnea. SN provided skilled instruction on daily weight monitoring at the same time each morning, low sodium dietary modification, and specific parameters for contacting the physician, including a weight gain of 2 pounds overnight or 3 pounds in one week, increased swelling, or worsening shortness of breath. Patient verbalized understanding and demonstrated the ability to state when to call. SN notified the physician office of the 4 pound weight gain, increased bilateral lower extremity edema, and reported orthopnea. Awaiting further orders. Patient remains homebound and continues to require skilled nursing for cardiopulmonary assessment, fluid status monitoring, and disease process management. SN to reassess weight trend, edema, lung sounds, and dietary compliance at the next scheduled visit.