HEARTFAILURECONGESTIVEHEARTFAILURE

DISCHARGEINSTRUCTIONS:GUIDELINESTOFOLLOWATHOME

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SPECIALINSTRUCTIONS:
CHFTeachingPacketgivenanddiscussed
CHFDischargevideoviewed
SuddenCardiacArrest(SCA)DVDviewed
SCATeachingPacketgivenanddiscussed
y Labs: ProBNP_____ Potassium_____

BUN_____

Creatinine_____
y EjectionFraction(EF)__________%
Date:________________________
MEDICATIONS:
y Youhavereceivedinstructionsonthemedicationsyourphysicianhasprescribedatdischarge.Alistofthese
medicationshasbeenprovidedtoyou.
y KeepalistofallcurrentmedicationsandthedateswhenyoureceivedtheFluandPneumococcal(Pneumonia)
Vaccines.
FluVaccinationDate:____________________________________
Pneumococcal(Pneumonia)VaccinationDate:____________________________________
ACTIVITY:
y Youcandonormaleverydayactivitiesasyourbodyallows.

y Takerestbreaksifyoufeeltired.Donotoverexert.

y Stopactivityifyouhavepain,shortnessofbreathorfeeldizzy.
Limitations:______________________________________________________________________________________
SMOKINGTOBACCOUSE:
y
Ifyousmoke,youarestronglyencouragedtostop.Ifyouhaverecentlyquitsmoking,congratulations!Forfurther
informationtostopsmokingortoremainsmokefree,callMGHRespiratoryTherapyat740.383.8711ortheOhio
TobaccoQuitLineat800QUITNOW(800.784.8669).
DIET:
y Followalowsodium(salt)diet.Yourdoctorrecommends:_________________________________________________
y Yourdoctormayalsorecommendafluidlimittoabout_________cups/day.
y Choosefoodsanddrinkswithlowornosalt.Removesaltshakerfromthetable.
y
FreeHeartHealthyEatingClassCall740.383.8484toschedule.
WEIGHTMONITORING:
y Weighyourselfeverydayatthesametimeandwriteitdown. yTakeyourweightlogtodoctorvisits.
y
Callyourdoctorifyougain35poundsover23days
yWeighttoday__________
EQUIPMENT/SUPPLIES: NotApplicable
HomeOxygen_____liters/min__________________company

HandHeldNebulizer(HHN) Scale
TREATMENTS:NotApplicable

REPORTTOYOURDOCTORORSEEKMEDICAL
HEARTATTACKWARNINGSIGNS
ASSISTANCE:
y Chestdiscomfort
y Shortnessofbreathorhavemoredifficulty
y Discomfortorpaininoneorbotharms,back,neck,jawor
breathing

stomach
y Swellingofyourfeet,ankles,handsorabdomen y Shortnessofbreath
y Feelingtiredwithnormalactivityorexperiencing y Breakingoutincoldsweat,nausea,orlightheadedness
dizzinessorfainting

y Troublesleepingorwakingupfeelingshortof
Ifyouarehavingheartattackwarningsigns:Call911
breathorcoughing

y Chestpainorpressure
Dontwaitmorethanafewminutes5minutesatmosttocall
y Weightgainof35poundsover23days
911.
y
Inabilitytotakemedicationsorfollowtreatment
plan
CHF DISCHARGE INSTRUCTIONS

PATIENT LABEL

z WHITE: CHART z YELLOW PATIENT z

z PINK: PHYSICIAN z

FORM # 536 CHF

FORMULATED: 10/01/04
REVIEWED: 5/06,8/06
REVISED: 8/06,3/08,10/08

December 9, 2008
H:\ClinicalPathways\CHF\HeartFailureCHFDischIns

HEARTFAILURECONGESTIVEHEARTFAILURE

DISCHARGEINSTRUCTIONS:GUIDELINESTOFOLLOWATHOME

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FOLLOWUPAPPOINTMENTS/OUTPATIENTSERVICES:
Unlessanappointmenthasalreadybeenmade,contactyourPrimaryCarePhysiciansofficetoscheduleafollowup
appointment.
DoctorDate/Time
Test/ProcedureDate/Time
OtherDate/Time

FollowUpEchocardiogram
REFERRALTOSOCIALWORKAGENCY?
YesNoIfyes,whichagency? ________________________________________________________________________

________________________________________________________________________

Thisformisnotallinclusive.Yourphysicianmaygive

youadditionalinstructions.Shouldyouhaveany

questions,pleasecontactyourphysician.Pleasebring
________________________________
_________________
thisdischargeinstructionformandthedischarge
PHYSICIANSIGNATURE(OPTIONAL)

DATE
medicationlisttoyournextphysicianappointment.

Ihavereadandunderstandmyplanofdischarge.

_____________________________
_________________
______________________________________ ______________
NURSESIGNATURE

DATE
SIGNATUREOFPATIENTORSIGNIFICANTOTHER DATE

CHF DISCHARGE INSTRUCTIONS

PATIENT LABEL

z WHITE: CHART z YELLOW PATIENT z

z PINK: PHYSICIAN z

FORM # 536 CHF

FORMULATED: 10/01/04
REVIEWED: 5/06,8/06
REVISED: 8/06,3/08,10/08

December 9, 2008
H:\ClinicalPathways\CHF\HeartFailureCHFDischIns