Heart failure patient guide by bob brocious

Living Well With Heart Failure Patient Guide

Table of Contents 1. H eart Failure • What is Heart Failure?....................................................................................................................................... 5 •C auses of Heart Failure..................................................................................................................................... 6 •D iagnosing Heart Failure.................................................................................................................................. 7 •C ategories of Heart Failure............................................................................................................................... 8 a. Heart Failure Stages....................................................................................................................................... 8 b.Heart Failure Classes...................................................................................................................................... 8 •T ake Control of Heart Failure.......................................................................................................................... 9 •M anaging Symptoms......................................................................................................................................... 9 2. Smoking Cessation • Heart Disease and Smoking........................................................................................................................... 13 •C igarette Dependence..................................................................................................................................... 15 •R eadiness to Quit............................................................................................................................................. 16 • S moking Triggers............................................................................................................................................. 18 • Quitting............................................................................................................................................................. 20 • S moking Cessation Products.......................................................................................................................... 21 3. Hypertension and Heart Failure.......................................................................................................................... 25 4. Medications................................................................................................................................................................. 31 5. Exercise......................................................................................................................................................................... 37 6. Nutrition •L ow Sodium Diet............................................................................................................................................. 49 a. Sodium Content of Foods........................................................................................................................... 49 b. Reading Labels............................................................................................................................................. 55 c. Seasoning without Salt................................................................................................................................ 50 d. Eating Out.................................................................................................................................................... 51 •F luid Restriction.............................................................................................................................................. 51 • Weight Management........................................................................................................................................ 52 7. Managing Heart Failure • I nfection Prevention........................................................................................................................................ 60 •D ay to Day........................................................................................................................................................ 60 • Air Quality Index............................................................................................................................................. 63 •H eart Failure and Depression......................................................................................................................... 63 8. Traveling with Heart Failure.................................................................................................................................. 68 9. Advanced Directives................................................................................................................................................ 72

SECTION 1

HEART FAILURE

What is Heart Failure?

There are 2 types of left-sided heart failure:

The Heart is an organ that pumps blood.

• Systolic failure: The left ventricle is not able to contract (squeeze) normally. The heart does not pump with enough force to push blood out to the body. • Diastolic failure (diastolic dysfunction): The left ventricle is not able to relax normally. The heart cannot adequately fill with blood during the resting periods between each beat.

Failure means unable to perform a normal function

Heart failure means that your heart is too weak to pump blood as well as it should, causing too much fluid to build up in the veins. You will sometimes hear Heart Failure referred to as Congestive Heart Failure or CHF. Heart failure can be either left-sided or rightsided. Heart failure does not mean that your heart is going to stop pumping.

Right-Sided Heart Failure

The right side of the heart takes the used blood from your body and sends it to the lungs to pick up oxygen before it goes to the left-ventricle to be pumped back out to your body. When the right side of your heart loses pumping power, blood backs up into the body’s veins causing swelling, usually in the feet and ankles.

Left-Sided Heart Failure

The left ventricle is responsible for pumping oxygen rich blood to the body. It is the largest chamber of the heart because it supplies most of the pumping power. When the left side of the heart loses pumping power, blood backs up into the blood vessels around the lungs causing fluid to leak into the lungs. This fluid causes congestion which makes it difficult to breathe.

Heart Failure is a Chronic Disease

Symptoms of Heart Failure

Illness can be either acute or chronic. Acute illness comes on quickly and lasts only a short time. It usually has only one cause and gets better with medication or surgery, rest, and time. Examples of acute illnesses are an infection or a broken bone.

It is important to know the symptoms of your heart failure in order to manage them. Managing your symptoms will reduce the frequency of exacerbations (“flare-up” of uncomfortable symptoms), slow down the progression of your disease, and improve your quality of life. Symptoms to watch for include:

Chronic illness is a disease which begins more slowly, worsens over time, and does not go away. Chronic disease may have many causes including lifestyle, heredity, environmental exposures, or physical factors. Heart Failure, also known as Congestive Heart Failure (CHF), is a chronic disease. Managing chronic disease can be difficult. Different chronic diseases may have some similar symptoms. Sometimes one symptom can cause other symptoms to worsen.

• Tiredness • Breathlessness • Weight gain • Swelling in the legs, ankles, and feet • Swelling in the abdomen • Swelling in the veins of the neck

While a chronic disease cannot be cured, symptoms can be managed. It is up to you to take charge of your illness. You can LIVE WELL with Heart Failure!

• Persistent cough, especially when lying down • Racing heart or irregular heart beat

Causes of Heart Failure

• Nausea or decreased appetite

The two most common causes of Heart Failure are Coronary Artery Disease (CAD) and hypertension (high blood pressure).

• Dizziness or lightheadedness

• CAD is when the arteries that supply blood to the heart muscle become narrowed by buildup of fatty deposits called plaque. • High blood pressure is the result of the arteries being unable to relax. They remain constricted (narrowed) and the force of blood pushing against the vessel walls puts extra strain on the heart and blood vessels. Other causes of heart failure includes:

You can live well with Heart Failure. It is up to you to take control.

• Diabetes • Heart valve disease • Cardiomyopathy (heart muscle disease) • Myocardial Infarction (MI or heart attack) • Congenital heart disease (birth defect) • Infection of the heart valves (endocarditis) or heart muscle (myocarditis) • Obesity (overweight) • Alcohol or drug use

B-type Natriuretic Peptide (BNP) is a substance secreted from the ventricles of the heart in response to changes in pressure and is measured by a blood test. The BNP rises as heart failure worsens. A normal BNP is below 100. Anything over 100 indicates some degree of heart failure. BNP may be used to help determine the severity of an acute exacerbation (flare-up) of Heart Failure.

Diagnosing Heart Failure Your healthcare provider may perform a variety of tests to diagnose and stage your heart failure and determine the best course of treatment for you. These may include: • Medical history • Physical exam

An electrocardiogram (EKG) is a simple, painless test that records the electrical activity of your heart. It shows how fast your heart is beating, if the rhythm is regular or irregular, and how well electrical impulses travel from one part of your heart to another. EKG’s can be used to detect problems that may contribute to heart failure.

• Symptoms • Echocardiogram • Cardiac catheterization • Blood tests • Electrocardiogram (ECG or EKG)

A chest x-ray may be helpful in diagnosing an acute exacerbation of Heart Failure. It will show your health care provider if you have an enlarged heart or pleural effusions (collection of fluid around the lungs).

• Chest x-ray

Ejection Fraction (EF) is a measurement of how well your heart is pumping and is one important consideration in diagnosing and staging heart failure. EF measures how much blood is being pumped out of your left ventricle with each beat of the heart. EF can be measured by echocardiogram or cardiac catheterization. If 60% of the total blood volume in the left ventricle is pushed out with each beat of the heart, then the EF is 60. A normal EF is 55-70. An EF of 40-55 implies damage, possibly from a previous heart attack, but may not mean you have heart failure. An EF of less than 40 implies heart failure. Not all people with heart failure have a low ejection fraction.

Your health care provider can use one or more of these tests to determine whether you have Heart Failure but the will also consider symptoms and other significant medical history when deciding the best course of treatment for you.

Categories of Heart Failure Your heart failure can be categorized in 2 ways: stages and classes. The stage of heart failure is determined by the actual physical condition of your heart in combination with your baseline symptoms. The class of your heart failure is determined by how you feel. Stages

There are 4 stages of heart failure: A, B, C, and D. Only your health care provider can determine the stage of your heart failure. STAGE A

You do not have heart failure now but are at high risk. High risk medical conditions include high blood pressure, diabetes, history of drug or alcohol abuse, family history of heart disease

STAGE B

Your heart is damaged, but you do not have symptoms yet. Heart damage may have been caused by a prior heart attack, heart valve disease, or cardiomyopathy (abnormal heart muscle)

STAGE C

Your heart is damaged and you sometimes have symptoms. Your heart failure sometimes causes you to have shortness of breath, tiredness, or less energy for normal activities

STAGE D

Your heart is damaged and you have severe heart failure symptoms. Your heart failure is bad enough that you continue to have symptoms even if you are following the treatments recommended by your health care provider

Classes

There are 4 classes of heart failure: I, II, III, and IV. You have been told by a health care provider that you have heart failure. The class of heart failure is determined by your symptoms (how you are feeling). The class of heart failure you are in can change. You may be in a higher class during an exacerbation (flare-up) and then return to a lower class when you are feeling better. CLASS I

Ordinary activity does not cause unusual tiredness, shortness of breath or palpitations (feeling strong, fast heart beat)

CLASS II (mild)

No symptoms at rest, but normal activity causes mild tiredness, shortness of breath, or palpitations

CLASS III (moderate)

Comfortable at rest, difficult to do normal activities because of symptoms

CLASS IV (severe)

Symptoms at rest, unable to do normal activities, symptoms increase with any activity

Take Control of Heart Failure

• Fullness or bloating in your stomach

Heart Failure cannot be cured, but it can be brought under control with medications and lifestyle changes. There are many things you can do to manage your heart failure such as:

• Intermittent or mild shortness of breath

• Follow a low-sodium ( low salt) diet

These can all be early signs that fluid is starting to build up. Try cutting the amount of sodium (salt) in your diet by 500 mg or ¼ teaspoon per day. Decrease your fluid intake by 1-2 cups per day. If your health care provider has explained to you how to adjust your diuretic (water pill) dose, then follow that advice. If your symptoms do not go awayin 1–2 days or worsen, call your health care provider to schedule an appointment.

• Eat a healthy, well balanced diet

Urgent Symptoms

• Stay physically active

• New or increased shortness of breath while resting

• Limit your fluid intake

• Trouble sleeping or waking up suddenly due to difficulty breathing

• Stop smoking • Take all of your medicines as directed by your health care provider

• Do not drink alcohol

• A need to sleep sitting up or propped up on more pillows than usual

• Weigh yourself daily • Watch for swelling

• Fast or irregular heartbeat or racing heart that makes you feel dizzy or lightheaded

• Notify your health care provider of worsening symptoms before they become severe

• Coughing up frothy or pink sputum

Heart Failure is a serious illness that can greatly affect your life, but it does not mean that you cannot enjoy your life. Together with your healthcare provider, you can learn ways to effectively cope with your disease, improve your level of fitness, prevent worsening symptoms, slow the progression of your disease, and live longer.

• Feeling like you may pass out These are urgent symptoms of heart failure. Call your health care provider or 911 immediately. Emergency Symptoms

• Chest pain or discomfort that lasts more than 15 minutes and is not relieved by rest or nitroglycerin (if prescribed)

Managing Your Symptoms

• Severe, persistent shortness of breath

Early recognition and treatment of symptoms can keep you out of the hospital. It is easy to fail to notice symptoms in the early stages or to shrug them off because you don’t feel that bad, but ignoring symptoms is risky. Even seemingly mild symptoms need to be taken seriously.

• Passing out You need to be treated right away! Call 911 immediately!

Early Symptoms

• Weight gain of 2 pounds overnight or 5 pounds in a week • Swelling in the legs, feet, hands, or ankles • Persistent cough or chest congestion • Increased fatigue or sudden decreased energy for usual activities • Loss of appetite or nausea 9

Notes

SECTION 2

SMOKING CESSATION

Heart Disease and Smoking

If you quit smoking you will:

About 20% of all deaths from heart disease in the United States are directly related to cigarette smoking. Cigarette smoke affects both smokers and non-smokers. When you smoke, the people around you are also at risk of developing health problems.

• Improve your quality of life

When you smoke, large amounts of nicotine and other toxic chemicals are quickly absorbed into your blood stream. These chemicals can cause damage to your heart by:

• Improve your sense of taste and smell

• Reduce your risk of complications from chronic disease • Cough less and breathe better • Save money • Smoking increases your chance of getting heart disease, having a stroke, and developing lung cancer

• Reducing the amount of oxygen that blood carries to the heart

• Within 1 to 9 months after quitting smoking, most people cough less and are less short of breath

• Increasing blood pressure and heart rate • Damaging cells in blood vessels, including the arteries in your heart • Increasing inflammation (swelling) in the lining of arteries • Increasing risk of blood clots

1. Effect of smoking on arterial stiffness and pulse pressure amplification, Mahmud A, Feely J. Hypertension. 2003:41:183 2. US Surgeon General’s Report, 1988, p. 202 3. US Surgeon General’s Report, 1990, pp. 193, 194,196, 285, 323 4. US Surgeon General’s Report, 1990, pp. 285-287, 304 5. U S Surgeon General’s Report, 2010, p. 359 6. A Report of the Surgeon General: How Tobacco Smoke Causes Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease Fact Sheet, 2010; and Tobacco Control: Reversal of Risk After Quitting Smoking. IARC Handbooks of Cancer Prevention, Vol. 11. 2007, p 341 7. A Report of the Surgeon General: How Tobacco Smoke Causes Disease – The Biology and Behavioral Basis for Smoking-Attributable Disease Fact Sheet, 2010; and US Surgeon General’s Report, 1990, pp. vi, 155, 165 8. Tobacco Control: Reversal of Risk After Quitting Smoking. IARC Handbooks of Cancer Prevention, Vol. 11. 2007. p 11

Fagerstrom Test for Cigarette Dependence The Fagerstrom Test for Cigarette Dependence is designed to help you and your health care provider have a discussion about your need to smoke. Please read each question below. For each question check (9) the box that best describes your response. 1. How soon after you wake up do you smoke your first cigarette: After 60 minutes.................. 9 0

Quitting is hard for anyone who smokes. Here are some tips to help you stop smoking:

31 – 60 minutes.................... 9 1 6 – 30 minutes...................... 9 2

• Try…and try again. Even if you’ve tried before.

Within 5 minutes................. 9 3

• Set a quit date and stick to it.

2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, at the movies, etc?

• Find out what makes you want to smoke. Then plan how to deal with these triggers. • Create a quit plan:

Yes.......................................... 9 1

– Quitting “cold turkey” may not work best for you.

No........................................... 9 0

– Consider enrolling in a quit-smoking program.

3. Which cigarette would you most hate to give up?

– Ask a friend or family member for support.

The first one in the morning. 9 1

• Make your home smoke-free.

Any other.............................. 9 0

– Ask friends and family members to not smoke around you.

4. How many cigarettes do you smoke a day? 10 or less................................ 9 0 11-20...................................... 9 1

Tell your health care provider you want to quit. He or she may be able to give you recommendations on how to quit. It’s never too late to quit smoking!

21-30...................................... 9 2 31 or more............................ 9 3 5. Do you smoke more frequently during the first hours after wakening than during the rest of the day? Yes.......................................... 9 1 No........................................... 9 0 6. Do you smoke even when you are so ill that you are in bed most of the day? Yes.......................................... 9 1 No........................................... 9 0 To find out your score, add up the numbers for each response. Higher scores may mean that you have a greater need to smoke. No matter what your score is, share this information with your health care provider. 15

I Am Ready to Stop Smoking!

Quitting takes time…but I’m taking positive steps: Check each statement that is true

I know it takes time to stop smoking. I’ll take it one step at a time. I feel that I am ready to take my first step. The statements below can help me understand why I want to quit smoking and why I think this is a good time to quit.

9 I have decided to quit — but I am not ready to set a date 9 I have set a quit date and I will quit on

Check each statement that is true.

_____________________________________________

I want to stop because:

_____________________________________________

9 I do not want to have bad breath 9 I do not like my smoking habit

9 I smoked my last cigarette and have gone 24 hours without lighting up

9 I am worried about my health

9 I have removed cigarettes from my pockets/purse

9 I want to look better

9 I have been a non-smoker for________________

9 I do not like the way my clothes smell

9 I request non-smoking rooms when I travel

9 I want to quit smoking for my family

9 I am proud of myself because________________

9 I want to feel in control

_________________________________________

9 Other reasons I want to stop

9 Other things I have done___________________

_____________________________________________

_________________________________________

_____________________________________________

_________________________________________

_____________________________________________

I want to stop now because:

I will celebrate the small steps! I will also:

9 I understand why I want to quit

Think about the reasons why I want to quit smoking. Ask for help if I need it.

9 My desire to stop smoking is strong

Talk with my health care provider.

9 I am able to manage this life change now 9 I am coping with home and work demands 9 I feel good and I have lots of energy to do this 9 I can take some time for myself if I need to deal with withdrawal 9 It is also a good time for me to stop because _____________________________________________ _____________________________________________ _____________________________________________

Why is quitting so hard?

What may help you quit smoking?

Three things usually work together to make you want to smoke

9 Talk to your health care provider about quitting smoking.

9 Nicotine addiction

9 Look at web sites such as www.smokefree.gov, which has information about quitting smoking.

Nicotine is the drug in tobacco that causes addiction. At first, nicotine causes you to feel good and may distract you from unpleasant feelings. Why? Smoking nicotine releases “feel-good” signals to the brain. This good feeling does not last long, making you want to smoke again. Over time, your body requires more nicotine to feel the same, which leads you to smoke more.

9 Join community programs for people who are trying to quit smoking. What are your ideas about what might help you? _________________________________________ _____________________________________________ _____________________________________________

9 Habit

Smoking can make you feel good, so you tend to do it over and over. Smoking also gives you something to do with your hands and mouth. As smoking becomes part of your routine, you no longer think about it — it is now a habit.

Talk to your health care provider about quitting. Make a plan. Stick to it. Get help if you need it.

9 Triggers

Triggers are things that make you want to smoke — like driving the car, finishing a meal, or being with other smokers. There are many other triggers, too. Each person may have a variety of them. What are some of your triggers? _____________________________________________ _____________________________________________

What are your smoking triggers? Triggers are things that make you want to smoke. When you know what your triggers are, you can plan to deal with them. The urge to smoke usually lasts just a few minutes. Here are some examples to get you started with activities to do instead of smoking. Add your ideas and place a check beside triggers that make you smoke. Write in a way to help you deal with each of them. My triggers 9 When I wake up and start the day.

Instead of smoking I will…

Take a shower immediately or go for a walk.

Your idea:

9 When I’m driving

Chew sugarless gum or sing along to music.

Your idea:

9 When I’m around other smokers.

Spend time in no-smoking places and with non-smokers.

Your idea:

9 When talking on the phone.

Hold a straw, doodle.

Your idea:

9 When I’m stressed

Exercise, take deep breaths, call a friend.

Your idea:

9 My morning coffee or tea 9 At work, during breaks 9 After each meal 9 Drinking or eating with friends

Knowing your triggers is an important first step toward quitting smoking. The next step is to work with your health care provider to find ways to deal with them.

My triggers

Instead of smoking I willâ&#x20AC;Ś

9 At the end of the work day 9 When I watch TV 9 When I am upset or have argued with someone. 9 When I am angry and cannot talk about it 9 When I am bored, nervous, or scared 9 When I feel lonely 9 After sex 9 When I am reading, writing, etc. 9 Other: 9 Other: 9 Other:

Try to stay away from your triggers. Ask your health care provider or a support person for help.

Sticking to quitting…

5. Change routines that include smoking.

Seven steps to help you stop smoking

Think about the times you automatically reach for a smoke. Create a plan to do something different. For example, if you usually smoke while:

Quitting smoking is hard. Here are seven steps that may help you. Put a check mark beside each action that you plan to try, and discuss these steps with your health care provider.

9 Drinking morning coffee — Change your morning routine. Drink tea or take a shower or a short walk before drinking coffee.

1. Handle stress without smoking.

9 Talking on the phone — keep your hands busy by doodling or drawing.

If you know about difficult times coming up at work, at school, or in your personal life, create a substitute plan for smoking during these times. For example:

9 Relaxing after meals — get up from the table right away, brush your teeth, take a walk.

9 Avoid the situation 9 Use a “quit-smoking” aid 9 Talk to a friend

What is your plan to do something different? _________________________________________

What makes you stressed? How will you handle it?

_________________________________________

6. Do not make weight gain your main focus.

_________________________________________ _________________________________________

If the thought of gaining weight is keeping you from quitting smoking, think about all the benefits instead. Try these ideas to help prevent gaining weight:

2. Drinking alcohol may affect your quit-smoking plan.

9 Plan time to exercise. Aim for 30 minutes of moderate exercise a day, 5 times a week

Drinking alcohol may be a trigger for smoking.

9 Drink water before and after meals

9 If you drink alcohol, talk to your health care provider about your plan to quit smoking.

What will you try?

9 Chew sugarless gum or eat sugarless candy

_________________________________________

3. Stay away from smokers.

_________________________________________

It is harder to quit when you are around smokers. When you first quit smoking:

7. Deal with cravings to smoke.

9 Try not to be near others that smoke 9A sk friends, loved ones, and coworkers not to smoke near you How will you try to stay away from smokers?

Cravings do not last long. They usually pass within a few minutes. 9 Stop what you’re doing and do something else

_________________________________________

What else can you do if you crave a cigarette?

_________________________________________

4. Keep substitutes for your cigarettes nearby.

_________________________________________

You may feel you need to have something in your mouth when you quit smoking. These substitutes may help: 9 Sugarless candy 9 Bottled water 9 Toothpick What will you use as a substitute? _________________________________________ 20

Help Someone You Care About Quit Smoking

You can also encourage your family member or friend to talk to his or her health care provider about the decision to quit. When someone you care about tries to stop smoking support them in this important decision!

When someone you care about stops smoking, you may both become healthier. Why? Smoking may be harmful to both smokers and those who breathe the secondhand smoke (smoke from someone elseâ&#x20AC;&#x2122;s cigarette).

Products to Help You Quit Smoking is a physical addiction and you may find that medications will help you quit.

People who choose to quit smoking deserve all the help you can give them, because it is very hard to stop. So when someone you care about quits smoking, support them in this important decision!

You may want to try over-the-counter nicotine replacement lozenges, gum, or patches.

How you can help

Ask the person who is quitting what are the best ways you can help. Check the boxes for the actions that you will take to support him or her. 9 Say how well they are doing E-cigarettes, also known as electronic cigarettes and vaporizer cigarettes are devices that emit doses of vaporized nicotine that are inhaled. Because e-cigarettes do not actually contain tobacco, they are not subject to U.S. tobacco laws. There is no data to support the effectiveness of e-cigarettes as an effective tool for smoking cessation. Long-term effects of the devices have also not been studied. The FDA and other regulatory agencies around the world are looking at these devices and considering restricting their use.

9 Say how pleased you are that they are quitting 9 Say that it is OK to talk to you whenever they need to 9 Encourage them to keep trying even if they are finding it hard to quit 9 Spend time doing things together to keep their mind off smoking 9 Help with chores or errands to lessen their stress 9 Celebrate milestones. Quitting is a big challenge! 9 Be there to listen What is not helpful

9 Do not nag, preach or scold You should ask your physician if prescription medication may be right for as you start your journey to a smoke-free lifestyle.

9 If they are grumpy from nicotine withdrawal, do not take it personally. Try to stay cheerful and listen. 9 Do not assume they will start smoking again if they slip 9 Do not offer advice. Just ask how you can help. If you smoke 9 Never offer them a cigarette

9 Do not smoke near them 9 Keep your cigarettes, matches, and lighters out of sight 9 Think about quitting too. Quitting together could make it easier for both of you.

Notes:

SECTION 3

HYPERTENSION AND HEART FAILURE

Hypertension (High Blood Pressure) Hypertension is a leading cause of heart failure. Getting and keeping your blood pressure under control is essential to slow the progression of your disease and to keep you well. Having consistently high blood pressure affects not only your heart and blood vessels, but it can damage your other body parts as well. What is blood pressure? Blood pressure is the force with which blood moves through your blood vessels (arteries and veins). Think of your blood vessels as strong, flexible, elastic hoses that carry blood from your heart to your lungs and other parts of your body. As blood moves through your vessels, it pushes against the walls of those vessels exerting pressure. If you constantly have too much pressure, your vessels can become stiff and damaged. Your health care provider looks at two different numbers when checking your blood pressure. The top number is called your Systolic Blood Pressure (SBP). This is the pressure exerted on the walls of your blood vessels each time your heart beats or contracts. Normal SBP is 100-120. The lower number is called your Diastolic Blood Pressure (DBP). This is the pressure exerted on the walls of your blood vessels each time your heart relaxes. Normal Diastolic Blood Pressure (DBP) is 60-80.

Many people with high blood pressure do not have symptoms. Even without symptoms high blood pressure is still doing damage to your body. It is often called â&#x20AC;&#x153;The Silent Killer.â&#x20AC;? This chart shows blood pressure categories as defined by the American Heart Association. Category

Systolic (upper number)

Diastolic (lower number)

Normal

Less than 120

Prehypertension

120-139

80-89

Hypertension Stage 1

140-159

90-99

Hypertension Stage 2

160 or higher

100 or higher

Hypertensive Crisis emergency care needed

higher than 180

higher than 110

and

Less than 80

It is a good idea to check your blood pressure regularly and write down the results. You should take your blood pressure readings to each health care visit. If you are not able to get a home blood pressure monitor, then you can use monitors located in many stores. Most stores with a pharmacy have blood pressure monitors that you can use free of charge. If your SBP is 160 or higher or your DBP is 100 or higher, call your health care provider.

• Stroke-High blood pressure can cause the blood vessels in your brain to become narrow and weak. They may even rupture causing your brain to hemorrhage (bleed). This is called a hemorrhagic stroke. High blood pressure can also cause clots to form in the arteries cutting off the blood supply to your brain and causing damage to brain tissues. This is called an ischemic stroke. Both types of stroke may be prevented by controlling your blood pressure.

Effects of Hypertension on Your Body BLOOD VESSELS Artery damage

• Arteriosclerosis, or hardening of the arteries is caused by high blood pressure damaging the cells that line your blood vessels. This causes the walls to become thick and stiff.

• Dementia-Blockages and narrowing of the arteries that supply blood to your brain may cause a disease called vascular dementia. Dementia is a brain disease that causes problems with thinking, speaking, memory, vision, and movement. This type of dementia can also result from stroke.

• Atherosclerosis is when blood passes through the damaged cells; fatty deposits collect on the walls forming plaque. This plaque causes your arteries to narrow. • Aneurysm-Over time, a constant high pressure pushing against the walls of an artery can cause a bulge called an aneurysm. If the aneurysm ruptures (breaks open), it can cause a life threatening bleed.

KIDNEYS • Kidney failure-High blood pressure is the leading cause of kidney failure. It damages the large arteries that carry blood to your kidneys and the tiny blood vessels within the kidneys. When these arteries are damaged your kidneys are not able to filter waste from your body and get rid of it (through urine).

HEART • Coronary Artery Disease (CAD) is a condition in which the arteries that supply the blood to your heart are narrowed by atherosclerosis. Narrowed arteries don’t allow blood to flow freely. When the blood is not able to flow freely, it can cause chest pain, arrhythmias (irregular heart rhythms) or heart attack.

EYES • Retinopathy-High blood pressure can damage the vessels that supply blood to your retina, the area on the back of the eye that sends pictures to the brain of what you see. Retinopathy can cause bleeding in the eye, blurred vision, and complete vision loss.

• Enlarged Heart -High blood pressure forces your heart to work harder than it should to pump blood to the rest of your body. This extra workload causes the left ventricle (the part of the heart that pumps blood throughout your body) to become thick and stiff. This can cause heart attack, heart failure, or sudden death.

• Optic Neuropathy-The optic nerve carries the pictures from your retina to your brain, enabling you to see. When the vessels that carry blood to optic nerve become blocked, it can kill the nerve cells in your eye that can lead to complete vision loss.

• Heart Failure-High blood pressure causes your heart to have to work too hard, weakening your heart muscle. It is not able to work as well as it should and eventually just wears out and starts to fail.

Good blood pressure control will help to keep your heart and other parts of your body healthy so that you can Live Well with Heart Failure!

BRAIN • Transient Ischemic Attack (TIA)-Sometimes called a mini-stroke, a TIA is when the blood supply to your brain is temporarily cut off because of narrowed arteries or a blood clot, both of which may be caused by high blood pressure.

(NAME) BLOOD PRESSURE LOG ________________________________________________

TAKE THIS WITH YOU TO EACH HEALTH CARE VISIT IF YOU GET A RESULT OF HIGHER THAN 160/100, CALL YOUR HEALTH CARE PROVIDER DATE

TIME

BLOOD PRESSURE

COMMENTS

Notes:

SECTION 4

MEDICATIONS

Medications Heart failure medicines are a very important part of keeping your symptoms controlled and keeping you out of the hospital. In heart failure, the heart cannot pump blood through the body as well as it should. Fluid builds up in the body which makes it hard to breathe and makes your heart work harder. Your feet and legs may become swollen. There are a lot of different medicines that can be used to help you manage your heart failure. They work in different ways. Your health care provider will determine which medicines are best for you depending on the stage and class of your heart failure, your symptoms, and your ability to obtain the medications. It is important that you know what medicines are prescribed for you, why you are taking them, and how to take them.

Medication Class

Examples

ACE-Inhibitor

Vasotec® (enalapril), Zestril® (lisinopril), Accupril® (quinapril)

ARB

Cozaar® (losarten), Diovan® (valsartan)

Beta-Blocker

Toprol XL® (metoprolol succinate), Coreg® (carvedilol)

Calcium-Channel Blocker

Norvasc® (amlodipine), Cardizem® (diltiazem)

Diuretics (Water Pills) Diuretics help your body get rid of extra water and salt through the urine. Getting rid of extra water makes it easier for your heart to pump. Diuretics may also help to lower your blood pressure. Diuretics are categorized as thiazide, loop, or potassium sparing. In addition to removing extra water, thiazide and loop diuretics also cause your body to lose potassium. You may need to take extra potassium if you are on these medicines. Potassium-sparing diuretics help your body to retain the mineral potassium and are often prescribed together with the other two types of diuretics.

You will likely be prescribed a combination of these medications in addition to any medicines that you take for other health conditions. It is important that you take your medications every day as prescribed by your health care provider in order to maintain a better quality of life and to stay as healthy as possible. Antihypertensive Medicines

Medication Class

Examples

Thiazide

HCT or HCTZ (hydrochlorothiazide)

Loop

Lasix® (furosemide), Bumex® (bumetanide)

Potassium-sparing

Aldactone® (spironolactone), Inspra® (eplerenone)

(Blood Pressure Medicine)

These medicines help lower blood pressure. They include ACE inhibitor, ARB, Beta Blockers, and Calcium Channel Blockers. ACE inhibitor—(Angiotensin-Converting Enzyme Inhibitor) Usually referred to as ACE-Inhibitors, these

Positive Inotropic Agents These medicines help to increase the force of your heart muscle’s contractions which helps your heart to pump better. Lanoxin® (digoxin) is a positive inotropic medicine.

medicines work by causing your blood vessels to relax and reduce strain on your heart. Most heart failure patients are on an ACE inhibitor. Angiotensin Receptor Blockers (ARB)

These medicines help to relax blood vessels to reduce strain on your heart. This medicine may be given to you if you are unable to take an ACE inhibitor. Beta-Blockers – help keep your heart from beating too quickly and help keep your heartbeat regular. It may help to slow down the progression of your heart failure. Calcium-Channel Blockers – slow down your heart rate and help your heart muscle relax, making it easier for blood to flow through the vessels. Calcium-channel blockers may be used in Diastolic Heart Failure. 31

Nitrates These medicines improve the supply of blood and oxygen to the heart by dilating blood vessels. Examples: ISDN, Isordil® (isosorbide dinatrate); ISMO® (isosorbide mononitrate)

Antilipemics (Cholesterol Therapy) These medications work to decrease total cholesterol, LDL cholesterol (bad cholesterol) and triglcerides. they increase HDL cholesterol (good cholesterol). Examples: Zocor® (simvastatin), Lipitor® (atorvastatin), Niacin

Antiplatelet Therapy These medications keep platelets from clumping together and are used to help keep coronary and peripheral artery stents from clogging up. Use of these medications can prolong bleeding time. Examples: Plavix® (clopidogrel), Aspirin

Anticoagulants This class of medications blocks specific clotting factors and slows or prevents clotting from occuring in the body. By preventing the body’s ability to clot you can prevent clotting issues such as deep vein thrombosis (DVT). Examples: Coumadin® (warfarin), Xarelto® (rivaroxaban)

Oxygen

At each health care visit: • Tell your health care provider about any side effects you are having

Many people with Heart Failure need supplemental oxygen (O2). It can improve your quality of life and may help you live longer. Oxygen is a medication. It requires a prescription and needs to be monitored regularly.

• Tell your health care provider about any other medications you have started or stopped taking, including any medicines that are over-the-counter (OTC), herbals, or vitamins

Your oxygen levels (O2 Saturation) will be tested with a pulse oximeter, a noninvasive device that is placed on your finger. The pulse oximeter shows how much oxygen is being carried by your red blood cells. You will be tested on room air (without oxygen), at rest and with activity. If your O2 saturation is too low, you will be placed on oxygen and tested again. This test will help your health care provider decide if you need oxygen and how much you need.

• Take all of your medicine bottles with you to each health care appointment • Check all of your medicines to see if you have refills left. Ask for refills on any prescriptions that will run out before your next health care appointment. • Talk to your health care provider about any questions or concerns you have regarding your health care or medicine(s)

If you do need oxygen, you may not need it all the time. Some people with heart failure only need oxygen with activity or at nighttime. Others need to wear it all the time. Your healthcare provider will let you know how much oxygen to use and when to use it.

Tips to Help You with Your Medicines • Set an alarm for the times that you need to take medicine.

• Leave yourself a note on the bathroom mirror

It is important to use your oxygen as prescribed by your healthcare provider.

• Keep your maintenance medicines in a place that you will see them every day • Write “refill medicine” on your calendar a week before you run out

Heart Failure Medication “to do” List

• Make sure you have enough refills to last until your next visit with your healthcare provider

Every day: • Take all of your medicines as directed by your health care provider

• Ask your pharmacy to send reminders when it is time to refill your medicine . It is safest to use one pharmacy for all of your medications.

• Write down any questions you have that are not an emergency so you do not forget to ask them the next time you see your health care provider • Monitor your symptoms and call your health care provider or go to the hospital if they get worse • Carry a current list of your medications (including prescription, over-the-counter, herbals, and vitamins) • Carry a list of drug and food allergies Every month: • Fill your medicine at the pharmacy

• Check your medicines to see if you have refills left. Call your pharmacy to ask for more refills before you run out of medicine. • Update your medication list and make copies to give to each of your health care providers 33

Notes:

SECTION 5

EXERCISE

Physical Activity and Heart Failure

Benefits Increased physical activity has many benefits for people with heart disease. Exercise can:

Heart failure poses many challenges including maintaining and increasing your level of activity. Many people with heart disease think it is impossible to include a higher level of activity in their daily routine. This is not true. People with Heart Failure must remain active! With planning and a few modifications, you can maintain an exercise program that will improve your quality of life.

• Strengthen your heart • Improve circulation and help your body use oxygen better • Lower blood pressure • Reduce body fat and build muscle

Why Do I Need to Lead an Active Lifestyle? Increasing physical activity will improve your quality of life. Cutting back on activity can cause a downward spiral to worsening heart disease. Shortness of breath, leads to decreased activity. Inactivity leads to a decline in fitness. A decline in fitness leads to increased shortness of breath. It is a vicious cycle that affects your overall health.

• Increase energy and improve strength • Reduce stress, anxiety, and depression • Improve sleep and help you feel more relaxed • Help you look fit and feel healthy Getting Started Start slowly. Regardless of your current level of fitness, making exercise a part of your daily routine is possible. It’s ok if you can only take a few steps when you start. Small increases in activity do make a difference. What type of exercise is best? Exercise can be broken into 3 basic categories:

• Stretching (Warm-up/Cool-down) • Cardiovascular or Aerobic • Strengthening. All of these areas should be included in your exercise routine.

This cycle can be reversed. As you increase your activity, your fitness level will improve. Improved fitness will result in increased energy and decreased tiredness. With an increased energy level, you will find that you are able to increase your activity and perform more everyday tasks. Increased activity will further increase your fitness level. The result is improved health.

General Exercise Guidelines • Always check with your health care provider before starting an exercise program

• Ask your health care provider how any newly prescribed medications may affect your response to physical activity • If you become overly tired or short of breath during exercise, sit down and rest for a few minutes • Avoid exercising outdoors during very cold or very hot weather • Avoid going up steep hills during physical activity; if you must go up hill, slow your walking pace

• Do not exercise if you feel ill or have a fever; wait a few days after symptoms disappear then restart slowly • Breathe! If you become too breathless to talk, slow down • Find a walking buddy to make exercise more enjoyable • Stop exercise and rest if you: Have chest pain Feel weak Ankle Pumping/Leg Circles Sit with your feet straight out in front of you. Keeping your heels on the floor, lift your toes up as far as you can. Hold for a count of five. For leg circles, rotate leg clockwise, then counterclockwise, as if drawing small circles. Repeat.

Are dizzy or lightheaded Have a fast or irregular heart beat or have palpitations Have pressure or pain in your chest, neck, arm, jaw, or shoulder If your symptoms do not go away with rest, call your health care provider or 911

Warm-Up/Cool-Down Exercises Stretching Stretching is the slow lengthening of muscles. It is important to stretch before (warm-up) and after (cooldown) exercise to prepare your muscles for activity and prevent muscle strain and injury. Stretching does not require any special equipment and, if necessary, can be done from a seated position.

Knee Straightening Raise your foot to fully straighten your knee out in front of you. Hold for a count of five. Lower your foot to the floor. Alternate legs. Repeat.

General guidelines while performing these exercises:

• Maintain good posture while performing these exercises - keep your back straight. Do not curve or slump your back. • Make sure your movements are controlled and slow avoid quick, jerking movements. Do not bounce. • Do not hold your breath during these exercises. If any of the following exercises causes pain, stop the activity and seek the advice of a physician, nurse or physical therapist.

Hip Bending Lift one knee up toward the ceiling. As you lower this knee, raise your other knee. Alternate each leg as if you were marching in place (while sitting). Repeat. 38

Single Arm Lifts Sit with your arms at your sides, fingers pointing toward the floor. Raise one arm out to your side, keeping your elbow straight and your palm facing down. Slowly lower your arm to your side. Repeat with your other arm. Repeat with both arms.

Overhead Reaching Raise one arm straight over your head, with your palm facing away from you. Keep your elbow straight. Slowly lower your arm to your side. Alternate arms. Repeat.

Single Shoulder Circles Bending one elbow, put your fingertips on your shoulder and rotate your elbow clockwise, then counter clockwise. Repeat with your other arm.

Calf Stretch Against Wall Stand facing the wall with your hands against the wall for support. Put one foot about 12 inches in front of the other.

Bend your front knee, and keep your other leg straight. (Keep both heels on the floor). To prevent injury, do not let your bent knee extend forward past your toes. Slowly lean forward until you feel a mild stretch in the calf of your straight leg. Relax, then repeat with your other leg. Repeat.

Aerobic Exercise

If you are in the green zone you are not working hard enough. If you are in the red zone, you need to slow down.

Aerobic or Cardiovascular Exercise Aerobic exercise is the steady use of large muscle groups. It strengthens your heart and lungs and improves your body’s ability to utilize oxygen. Regular aerobic exercise can decrease your heart rate and blood pressure, and lessen fatigue and shortness of breath. Aerobic exercises include walking, bicycling (stationary or outdoors), low-impact aerobics, and water aerobics. Two things that you should do with aerobic activity are:

• You should wait at least 90 minutes after eating a meal before aerobic exercise • Include a five minute warm-up/five minute cooldown with aerobic activity Walking is a great form of aerobic exercise and it can be done without a gym membership or any special equipment. If you are unable to walk distances, then start slowly. If you can only walk 30 seconds or 1 minute at a time, then do it 5 times a day. Once you are able to walk 5-7 minutes at a time, decrease the frequency to 4 times a day. When you are able to walk 10 minutes without stopping, you may do it only 3 times a day. Try to work up to walking 30 minutes without needing to stop. Your goal should be 30 minutes of walking daily. Walking can be done indoors or outdoors. If you are planning to walk outdoors, it is important to consider pollen levels, temperature, environmental irritants, and, if needed, resting areas. Indoor walking may be a good option for you. Mall walking is good way to get your aerobic exercise. Malls provide an environment with a controlled temperature. There are usually benches situated throughout the mall, so you can stop and rest if you need to. Another good indoor place to walk is in a grocery store or department store. You can use a shopping cart to help steady yourself and lean on it if you become fatigued. The goal of aerobic exercise is endurance, not intensity. Use your level of exertion and breathing effort to guide you. If you are not able to talk while you are exercising, you are working too hard. If you are able to speak easily with no additional effort, you are not working hard enough. Use the chart below to judge your activity level. You should try to exercise in the yellow zone. 40

Strengthening

Be sure to exercise all of the major muscle groups, including: • Upper body: arms, shoulders, chest, and upper back

Strengthening is the repeated contracting (tightening) of muscles until they become tired. Strength training should be done 2-3 days a week. There are several simple strengthening exercises that you can do at home without a gym membership or any special equipment. Soup cans or water bottles can serve as free weights. Ankle weights can be made by filling a sock or sleeve from an old shirt with sand, rice, or pebbles.

• Middle body: stomach and lower back • Lower body: hips and legs Start out slowly • Add exercises over time so that you are doing various exercises that cover all major muscle groups

If you have not been doing strength training as part of your daily routine, you should start these exercises without using weights. Free weights and ankle weights should be added as your fitness level improves.

When starting out, you may benefit from working with a fitness professional to learn: • How to stick to your program

Strength training basics

• How to reduce the risk of injury during exercise

For most adults strength training is a safe and effective addition to an exercise program Strength training can:

Talk to your healthcare provider before you begin an exercise program.

• Help you burn calories • Increase your muscle strength • Improve balance, coordination, mobility • Increase the strength of your bones • Help decrease symptoms of some chronic conditions including arthritis • Have many benefits, especially as you get older Strength training can be done using your body weight (like push-ups), free weights (dumbbells), machines, or resistance bands. The American College of Sports Medicine recommends strength training for adults 2 to 3 times a week.

• 8-12 repetitions for 2-4 sets is recommended • Repetition means how many times you lift the weight • A set is a group of repetitions • Rest for 2-3 minutes between sets • Use lighter weights and do more repetitions if you want to improve muscle endurance • Use heavier weights and do fewer repetitions if you want to increase muscle strength

Strength training without a gym – Level 1

Wall push-ups Why: Strengthens arms, shoulders, and chest

Strength training can help you feel stronger and healthier. Strength exercises help burn calories during and after exercise. What you need: • Good shoes (walking, running, or cross-training sneakers)

• Loose, comfortable clothing (for example, a cotton T-shirt and cotton shorts or pants) • Chair • Exercise mat or towel over carpet

How:

Strength training can be done using your body weight (like push-ups), free weight (dumbbells), a medicine ball, or resistance bands.

• Face the wall, lean forward with palms flat against the wall at shoulder width and height • Keeping your body straight, bend your elbows and slowly lean into the wall (do not move your feet)

Warm-up Warm up with 5-10 minutes of any activity that slowly raises your heart rate, like marching in place, jumping jacks, or walking up and down the stairs.

• Pause, then push back to a count of 2 • Repeat 10 times • Rest for 1 or 2 minutes, then do this one more time

Exercises (Weeks 1 and 2)

Toe stands Why: strengthen calves and ankles

Squat with chair Why: strengthens hips, thighs, and buttocks How: When you first start this exercise, you may not be able to squat very far. You may use your hands to assist you, or squat only a couple of inches at first.

How: • Hold onto a counter or chair back for balance

• Hold your arms straight out in front of you, and lean slightly forward from your hips with your back flat

• Standing with your feet shoulder-width apart, rise onto the balls of your feet to a count of 4, and hold for 2-4 seconds

• Slowly lower yourself to a near sitting position to the count of 4, with most of your weight on your heels (do not let your knees go over your toes)

• Then lower your heels down to a count of 4

• Pause,then slowly rise back up to standing to a count of 2 • Repeat 10 times • Rest for 1 or 2 minutes, then do this one more time

• Repeat 10 times • Rest for 1 or 2 minutes, then do this one more time • Keep good posture and a straight back during the entire exercise Exercise while you sit What you need:

• A sturdy chair with no arms

Waist: Sit with your feet flat on the floor. Sit forward a bit on the seat, keeping your back straight. Hold your arms up in an “L” position so your fingers are pointing up to the ceiling. Twist right then left from the waist. Do 1 set of 16 reps on each side.

• Light hand-held weights. You can use any two samesize items, such as canned soup or water bottles. You can also do all of these exercises without weights. How to count your exercises: • Each move is called a repetition (rep) • Each series of reps is called a set Talk to your healthcare provider about a plan that is right for you. Stomach: While sitting on a chair with your feet on the floor, put your hands behind your head. Bend at the waist towards your knees. Sit back up straight. Begin with 1 set of 10 reps. Add one more set at a time until you feel you have reached your limit.

Shoulders: Pick up a weight in each hand. Start with your arms and weights down at your sides. Slowly raise the weights in front of you so they are at shoulder level. Your arms should stay straight, palms facing the floor. Lower them back down to the starting position. Do 1 set of 8 reps. Repeat 1 more set. You may also do this exercise one arm at a time.

Inner thighs: Place your feet together on the floor and let your knees separate. Place a hand on the inside of each knee. Try to close your knees while your hands try to keep them apart. Your knees should stay in the same position while you do this, as you count to 5. Repeat another count of 5. Later, lengthen the amount of time you do this press.

Chest: With elbows out to the side and chest high, hold the weights together in front of your face. Pull the weights apart, staying level, until your elbows can go no farther without going behind you. Return to starting position. Do one set of 8 reps. Repeat 1 more set.

Shoulder rolls: Roll both shoulders back and around. Do this 4 times, then change direction and roll both shoulders forward 4 times. Now, lift the right shoulder up toward your ear, hold, and then let it drop. Repeat on the left side.

Notes: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Biceps: Sit up with your feet on the ground. Hold one weight in your right hand. Press your arm against your body for support. Starting at knee-level with your palm facing up, lift the weight until it almost touches your shoulder. Lower back to starting position. Be sure to keep your wrist straight. Do 1 set of 8 reps. Take a short rest. Repeat the set. Then do 2 sets of 8 reps with your left arm.

_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Triceps (back of arms): With both hands extending above your head, hold a single weight with both hands. Keeping your upper arms still, bend your elbows to lower the weight behind your head. Now press the weight back up to the starting position. Do 2 sets of 8 reps.

Fitness facts and fiction

Lifting weights will make me gain weight and inches as I build muscle. False. You will probably not gain weight unless you eat more calories. Strength training helps you gain muscle and lose body fat. Because muscle is denser than fat, it takes up less room. So you may stay the same weight but lose inches. You may even lose weight as you burn calories.

Is there something that is keeping you from reaching your fitness goals? Find out what’s true and what’s not to help make your fitness program a success. There is only one right way to exercise. False. You don’t have to exercise intensely for long periods of time. Exercising for 10 minutes 3 times during the day works as well as exercising for 30 minutes all at once. Try doing different exercises during each 10 minute period. Just be sure to keep your exercise level moderate to vigorous. In addition, you don’t have to exercise in a gym. You can also exercise at home or outdoors. Good choices include fast walking, bike riding, tennis, pushing a lawn mower, swimming, jogging, or running.

If I only have time to exercise a few minutes a day, it’s not worth doing at all. False. No matter what your age or health, any exercise is better than none at all. Benefits increase the more exercise you do. Regular exercise may help me live longer. True. Compared with leading a physically inactive life, exercising regularly can help reduce your risk for some chronic diseases, such as heart disease, high blood pressure, and diabetes.

If I exercise I can eat more and not worry at all about gaining weight. False. Losing weight depends on burning more calories than you eat. The best way to lose weight or maintain a good weight is to exercise regularly and eat proper portions of healthy foods. I’m already tired. Exercise will make it worse. False. Exercise may improve your energy level. Do not skip your exercise session because you feel tired. Exercise at a lower level. You’ll get the benefits of exercise and boost your energy level. If I do aerobic exercise more vigorously, I can exercise for less time and still get the health benefits. True. One minute of vigorous-intensity aerobic activity is about the same as 2 minutes of moderateintensity aerobic activity. You know you are exercising vigorously if you can’t say more than a few words without pausing for a breath. If you are exercising at moderate intensity, you can talk but not sing. Health benefits result from 150 minutes a week of moderateintensity or 75 minutes a week of vigorous-intensity aerobic physical activity.

SECTION 6

NUTRITION

Healthy Eating

You can also check the front of the food package to quickly identify foods that may contain less sodium. For example, look for foods with claims such as:

Good nutrition is important for managing any chronic disease, including Heart Failure. Food provides your body with fuel to produce energy for all activities. Sometimes it is difficult to eat, especially when you are having an exacerbation, but good nutrition and maintaining a healthy weight are very important.

• Salt/Sodium-Free → Less than 5 mg of sodium per serving • Very Low Sodium → 35 mg of sodium or less per serving

If you are overweight, your heart and lungs must work harder. Extra weight causes your body to need more oxygen. The extra weight also puts more pressure on your heart and lungs and makes it harder to breathe. A healthy diet can help you to reduce your weight and make breathing easier. Do not skip meals to try to lose weight! Skipping meals causes your metabolism to slow down and makes weight loss more difficult. If you are overweight, talk to your health care provider about starting a healthy weight-loss program.

• Low Sodium → 140 mg of sodium or less per serving

If you are underweight, you may feel weak and tired. If you are not eating a healthy diet, your body will burn muscle for energy (muscle wasting) and your muscles will become weak. A healthy diet can help you gain weight, build muscle, and give you more energy. Do not skip meals! Skipping meals will cause you to become more weak and tired.

Low-Sodium Eating

• Reduced Sodium → At least 25% less sodium than in the original product • Light in Sodium or Lightly Salted → At least 50% less sodium than the regular product • No-Salt-Added or Unsalted → No salt is added during processing, but not necessarily sodiumfree. Check the Nutrition Facts Label to be sure!

Reducing the amount of sodium in your diet is an important step in controlling your Heart Failure. Following a low-sodium diet can help you feel better and prevent new or worsening heart problems. Limiting sodium in what you eat and drink helps prevent the buildup of extra fluid around your heart and lungs and in your abdomen and legs.

Sodium as a Food Ingredient The words “salt” and “sodium” do not mean the same thing, but when talking about food are often used interchangeably. Sodium is one ingredient found in salt, but it is in other food additives as well. MSG, baking soda, and other food ingredients that you may use also contain sodium. It is important to check the sodium content on food and drink labels when preparing meals and snacks.

Extra Fluid • Makes your heart work harder

• Increases your blood pressure • Causes weight gain • Causes swelling in your feet, legs, and abdomen Limiting Sodium • A teaspoon of salt contains 2300 mg of sodium

Use the Percent Daily Value (%DV) to Compare Products The %DV tells you whether a food contributes a little or a lot to your total daily diet. 5%DV (120 mg) or less of sodium per serving is low. 20%DV (480 mg) or more of sodium per serving is high.

• Limit your sodium intake to less than 1500 mg per day, less is better • Try to select foods with no more than 140 mg of sodium per serving • Try to limit sodium to less than 500 mg per meal • Avoid using salt at the table or keep a small shaker with

1/8 teaspoon of salt and use as a daily allowance

• Replace the salt in the shaker with a salt-free seasoning such as Mrs. Dash®

Good Food Choices • Fresh or frozen fruits without added salt or sugar

Seasoning Without Salt Many herbs and spices do not contain salt and are a great way to season foods. Listed below are seasoning suggestions for various foods.

• Fresh or frozen vegetables without sauces • Fresh or frozen leafy greens without sauces-spinach, kale, turnip tops • Canned vegetables with no added salt

BEEF

bay leaf, dry mustard, green pepper, marjoram, fresh mushrooms, nutmeg, onion, pepper, sage, thyme

CHICKEN

green pepper, lemon juice, marjoram, fresh mushrooms, paprika, parsley, poultry seasoning, sage, thyme

FISH

bay leaf, curry powder, dry mustard, green pepper, lemon juice, paprika

LAMB

curry powder, garlic, mint, mint jelly, pineapple, rosemary

PORK

apple, applesauce, garlic, onion, sage

VEAL

apricot, cinnamon, cloves, ginger

EGGS

dill, dry mustard, garlic, green pepper, onion, pepper, parsley, rosemary, tarragon

BREADS

cinnamon, cloves, dill, poppy seed

PASTA

basil, caraway seed, garlic, oregano, poppy seed

RICE

chives, green pepper, saffron, onion

VEGETABLES

garlic, lemon juice, onion, vinegar, dill, ginger, marjoram, nutmeg

• Mixes-cornbread, biscuits, cakes, puddings

POTATOES

green pepper, garlic , onion, paprika, parsley, mace

• Deli or lunch meats-bologna, ham, turkey

SQUASH

cinnamon, nutmeg, mace, ginger

• Cured or smoked meats-sausage, corned beef, hot dogs, bacon

DESSERTS

allspice, anise, cinnamon, cloves, ginger, mace, nutmeg, vanilla extract, other extracts

• Canned fruits packed in 100% juice • Fresh lean meats-check the package label to see if saline (salt-water) has been added • Fat-free or low-fat milk, yogurt, and sour cream • Low-sodium cheeses • Unsalted nuts and seeds • Eggs and egg substitutes • Dry or canned beans without salt • Whole grains-brown rice, barley, quinoa, oats • Dark chocolate (greater than 70% cocoa solids) Foods to Avoid • Canned foods unless it states “no added salt” on the label

• Frozen dinners, snacks, and vegetables with sauces • Pre-packaged snacks-salted chips, popcorn, pretzels, pork rinds • Pre-packaged foods-seasoned noodle or rice dishes, stuffing mix, convenience foods • Instant cooking foods (just add hot water)

• Canned meats or spreads • Processed cheese foods and cheeses containing more than 140 mg sodium per serving

When cooking with herbs and spices, remember that the flavors become stronger over time. You may not taste the flavor that you want immediately. Let the flavor of the spices develop before adding more. A little goes a long way.

• Condiments-prepared mustard, ketchup, salad dressings • High-sodium seasonings-bouillon cubes or granules, meat tenderizer, garlic salt, celery salt, onion salt • Prepared sauces-Worcestershire, soy, barbecue, steak, pizza or spaghetti, cheese • Dried fruits prepared with sodium-containing additives

Restricting Fluids

Tips for Eating Out

Limiting the amount of fluids that you drink each day is an important part of managing your Heart Failure. You should not drink more than 8 cups of fluid daily (1 cup = 8 ounces). Your health care provider may instruct you to limit your fluids even more. It is important to remember that if a food is liquid at room temperature, then it counts as fluid. Fruits with high water content also count.

It is easier to control the amount of sodium and fat in your food when you are cooking at home. Dining out can be a challenge. Follow these simple suggestions, and you can still enjoy restaurant dining occasionally.

• Water

• Ask for meat or fish to be broiled

• Request food to be prepared without salt • Ask for sauce, salad dressing, and gravy to be served on the side so that you can control the amount that you use

• Milk

• Use pepper or lemon juice instead of salt for flavor

• Coffee, tea

• Bring your own salt-free seasoning

• Fruit and vegetable juices

• Recognize words that indicate high sodium content: marinated, pickled, smoked, au jus, teriyaki, soy sauce, broth

• Soft drinks-soda, Kool-Aid® • Soup

• Watch portion sizes-ask for half of your meal to be boxed up to take home with you

• Jell-o® or gelatin desserts • Frozen desserts-ice cream, frozen yogurt, sherbet, fruit ices • Ice cubes and crushed ice • Watermelon, grapes, citrus fruits (1/2 cup serving = 1/4 cup liquid) Tips to help you stick with your fluid restriction • Use a pre-measured bottle or container and fill with your total allowed fluid for the day. As you drink or eat fluids, remove the same amount from your container.

• Drink from small cups • Take your medications with meals, if possible, rather than using separate fluid. Check your medicine labels-some medicines should be taken without food. • Sweet foods/drinks increase thirst. Replace sweets with tart or sour foods/drinks such as lemonade or limeade or sugar-free lemon drop candy • Freeze drinks to slushy consistency instead of adding ice • Eat frozen fruits in place of other frozen desserts • Chew gum, suck on a lemon wedge, or use commercially prepared products such as Biotene®, OraMoist® and others to moisten a dry mouth

Healthy Weight Management

Overweight or unintentional weight gain: • Don’t skip meals. Eat frequent small protein-containing snacks

Achieving and maintaining a healthy weight is important for everyone. People at a healthy weight tend to have better blood pressure, tolerate more physical activity, and recover more quickly from illness than those who are overweight or underweight. It is extremely important that you DO NOT SKIP MEALS in order to achieve and maintain healthy weight.

• Avoid sweets, sodas, and other ‘empty calories’ • Include some activity, about 30 minutes, every day • Eat more fruits, vegetables, and whole grains for fiber • Limit sodium (salt) to reduce fluid retention • Limit serving sizes to healthy portions

Underweight or unintentional weight loss: • Drink milk or high-calorie ‘shakes’ between meals

• Drink low-calorie fluids

• Try supplements like Boost Plus, Ensure, or Carnation Instant Breakfast

General Nutrition Guidelines

• Avoid low-fat or fat-free foods; eat a moderate amount of fat daily

Whether you are overweight or underweight there are some general diet guidelines that you should follow.

• Avoid sweets, sodas, and other ‘empty calories’

• Drink 6-8 cups of non-caffeinated, low-sugar liquids daily, unless directed otherwise by your health care provider.

• Don’t skip meals • Include some activity, about 30 minutes, to stimulate muscles

• Eat at least 6 ounces of lean protein every day. Eating enough lean protein will help prevent muscle wasting.

• Use ‘calorie boosters’ to add calories to your favorite foods

• Try to get 20-35 grams of fiber every day. Good sources of fiber are fruits, vegetables, nuts, beans, and whole grains. Fiber aids in digestion, helps control cholesterol and blood glucose levels, and provides important nutrients that help protect your body.

Calorie Boosters

• Include 2-3 servings of “good fats” daily. Good fats (monounsaturated or polyunsaturated) can be found in canola, olive, or corn oil, nuts, fish and seafood. Limit saturated fats found in beef, butter, lard, and fried foods.

• Whole egg or yolk • Non-fat powdered milk or evaporated milk • Cream cheese • Shredded/melted/sliced/ cubed/ grated cheese • Mayonnaise, butter, margarine, sour cream • Vegetable oils • Peanut butter • Nut dust (ground nuts) • Jelly or jam • Honey, maple syrup

• Control your sodium (salt) intake • If you take diuretics (water pills), eat foods high in potassium like bananas, oranges, and tomatoes. • Avoid overeating. Eat 5-6 small meals a day instead of 3 large meals. Avoid foods that cause gas or bloating. • Look at the nutrition labels on food when you are at the grocery store. Understanding food labels will make it easier to choose healthy foods.

Heart Failure Sample 1-Day Menu Breakfast

1 cup regular oatmeal 8 oz. 1% fat milk 1 medium banana 1 slice whole wheat bread with 1 teaspoon soft margarine

Lunch

Fruit platter with 1/2 cup fresh strawberries, 1/2 orange (sliced), two peach halves 3/4 cup low-sodium cottage cheese 5 unsalted crackers

Evening Meal

3 oz. herb baked fish 1 baked potato with 2 tablespoons soft margarine Sliced tomatoes 1/2 cup steamed spinach drizzled with lemon juice Baked apple

Snacks

1 cup low-fat pudding 1/2 low-sodium turkey sandwich on whole wheat bread 2 tablespoons salt-free peanut butter with 5 low-sodium whole grain crackers

Notes:

Sample Meal Plan - use this form to develop an individualized meal plan. Breakfast

Lunch

Evening Meal

Snacks

Notes:

Food Label Facts In order to eat a healthy diet, you need to know what is in your food. Reading food labels is one way to ensure that you are getting enough of the nutrients that you need while limiting the less healthy nutrients. • Start with the serving size. Many foods have more than one serving per container. All the nutrition information listed on the label is based on one serving of the food. • Check the calorie count. Remember, the calories listed are per serving, not per package. • Daily Value (DV) Daily values are based on a 2000 calorie/day diet. Your daily calorie needs may be different based on your age, health conditions, lifestyle, weight, and gender. Your health care provider can help you decide how many calories you need each day to be healthy. The amount of each nutrient per serving is listed in grams (g) or milligrams (mg). The % DV tells you how much of your daily need of each nutrient you are getting in one serving.

Free, Lite, Low, Reduced… It’s Not What You Think

If a food claims to be...

In addition to the Nutrition Facts label on foods, you need to watch for words like FREE, LITE, LOW, and REDUCED. You need to know what these words really mean in order to make heart healthy choices. If a food claims to be...

It means that one serving of the product contains...

Calorie free

Less than 5 calories

Sugar free

Less than 0.5 grams of sugar

Sodium

Less than 0.5 grams of fat

Low fat

3 grams of fat or less

Reduced fat or less fat

At least 25 percent less fat than the regular product

Low in saturated fat

1 gram of saturated fat or less, with not more than 15 percent of the calories coming from saturated fat

Lean

Less than 10 grams of fat, 4.5 grams of saturated fat and 95 milligrams of cholesterol

Extra lean

Less than 5 grams of fat, 2 grams of saturated fat and 95 milligrams of cholesterol

Light (lite)

At least one-third fewer calories or no more than half the fat of the regular product, or no more than half the sodium of the regular product Less than 2 milligrams of cholesterol and 2 grams (or less) of saturated fat

Low cholesterol

20 or fewer milligrams of cholesterol and 2 grams or less of saturated fat

Reduced cholesterol

At least 25 percent less cholesterol than the regular product and 2 grams or less of saturated fat

Less than 5 milligrams of sodium and no sodium chloride in ingredients

Very low sodium

35 milligrams or less of sodium

Low sodium

140 milligrams or less of sodium

Reduced or less sodium

At least 25 percent less sodium than the regular product

High fiber

5 grams or more of fiber

Good source of fiber

2.5 to 4.9 grams of fiber

If you can’t remember the definitions of all of the terms, don’t worry. You can use these general guidelines instead: • “Free” means a food has the least possible amount of the specified nutrient. • “Very Low” and “Low” means the food has a little more than foods labeled “Free.” • “Reduced” or “Less” mean the food has 25 percent less of a specific nutrient than the regular version of the food.

Cholesterol Cholesterol free

Sodium free or no sodium

Fiber

Fat Fat free

It means that one serving of the product contains...

Notes:

SECTION 7

MANAGING HEART FAILURE

Avoiding Flu and Pneumonia

Day-to-Day Management

Flu and Pneumonia are more dangerous for people who have heart failure than for healthy people. Influenza (flu) is a respiratory illness that is caused by a virus. Death from flu is more common among people with heart disease than among people with any other chronic disease. Pneumonia is a lung infection that keeps your body from using oxygen as well as it should. Your heart has to work harder to pump oxygen-rich blood through your body. People with heart failure should avoid putting extra strain on their hearts. Pneumonia can sometimes be a complication of flu.

Step on the scale One important way to monitor your heart failure is to weigh yourself every day. You should weigh yourself in the morning after you go to the bathroom and before you eat or drink anything. Keep a written record of your daily weights and take it with you to each health care appointment. Call your health care provider if you have a weight gain of 2 pounds overnight or 5 pounds in a week.

Many people with chronic diseases like heart failure become very ill during flu season. You need to take steps to protect yourself.

Limit your salt and fluid intake Limiting your salt and fluid intake will help prevent fluid retention. Excess fluid in your body can cause swelling in your feet, ankles and abdomen. Excess fluid around your lungs will make breathing more difficult.

• AVOID GERMS! Stay away from people with colds and flu. The droplets from coughs and sneezes are full of germs and end up on handrails, doorknobs, shopping carts, and anything that other people touch.

Stay physically active Regular physical activity helps make your muscles stronger. This may give you more energy to perform everyday tasks and help you to feel better.

• Stay out of crowds, especially during flu season (October-March). You are more likely to come in contact with infected people in crowded places.

Prevent infection Infection puts extra stress on your heart. Some ways that you can help prevent infection are good hand washing, staying away from people that you know are sick, and getting vaccinated against flu and pneumonia.

• Wash your hands often. Hand washing is the single most important way to prevent the spread of germs.

Stay away from smoke Exposure to second hand smoke poses the same health risks as smoking. Avoid areas where people are smoking. Ask your family and friends to step outdoors to smoke, or better still, encourage them to quit smoking.

• Get a flu shot the end of September or early October every year. • Ask your health care provider if the pneumonia vaccine is right for you. If the vaccine is recommended, you should get one now and a second shot at age 65. Your health care provider may want you vaccinated more frequently.

Avoid alcohol Drinking alcohol contributes to high blood pressure and can worsen heart failure. Alcohol is poison to the heart muscle. It further weakens your heart, decreasing pumping action. Alcohol is also high in calories.

Avoiding infection is an important step in Living Well with Heart Failure!

Maintain a healthy weight Unhealthy weight contributes to heart disease. Obesity (overweight) may cause blood pressure and cholesterol to increase making your heart work harder. Being underweight is equally as bad. Your body needs to burn fat for energy. If there is not enough fat, your body burns lean muscle (muscle wasting), including cardiac muscle, for energy.

Monitor your symptoms Recognizing and monitoring symptoms are keys to managing heart failure. Sudden weight gain, swelling, worsening cough, and increased breathlessness can all be signs of an exacerbation. It is important to recognize symptoms and notify your health care provider before they become severe. Early recognition and treatment of worsening symptoms can keep you out of the hospital and improve your quality of life.

Symptoms of heat stroke are:

• Warm, dry skin with no sweating • Strong, fast pulse • Confusion or unconsciousness • High fever • Throbbing headache • Nausea and/or vomiting Heat stroke is a medical emergency that requires immediate medical attention. Call 911!

Avoid very cold and very hot weather Extreme temperatures can trigger changes in blood pressure, blood thickness, and heart rate all of which can place excess strain on your heart.

Cold weather can be hard on your heart, especially if you have heart disease. Cold temperatures and winds can rob your body of heat. Your heart has to work harder circulating blood to keep your body warm. Exertion like shoveling or even walking through heavy, wet snow also puts extra strain on the heart, increasing blood pressure, and increasing risk of heart attack and stroke. The coldest months of the year are December and January. Heat and humidity can be hard on your heart as well. Hot, humid air is heavier than dry air and is more difficult to breathe in. Additionally, the medications used to treat heart failure may make you more sensitive to heat. Heat exhaustion and heat stroke are heat related conditions that can place undue strain on your heart. Symptoms of heat exhaustion are:

• Headache • Heavy sweating • Cold, moist skin and chills • Dizziness or fainting • Weak, fast pulse • Muscle cramps • Fast, shallow breathing • Nausea and/or vomiting If you experience symptoms of heat exhaustion, move to a cooler place, stop exercising, and drink cool water. If your symptoms do not improve, seek medical attention.

Living Well with Heart Failure TAKE IMMEDIATE ACTION • Unrelieved shortness of breath at rest • Unrelieved chest pain • Passing out

YOU NEED TO BE TREATED — CALL 911

CAUTION • Increased weight of 2 lbs overnight or 5 lbs in a week • Wheezing or chest tightness at rest • Increased swelling of ankles, feet or legs • Increased shortness of breath with activity • Increased use of pillows or need to sit in a chair to sleep Unusual symptoms that bother you such as dizziness or new or increased confusion. If you have any of these symptoms, you may need a change in your medications. If you have a rescue plan, start now. Call your doctor for an appointment as soon as possible.

ALL CLEAR • At baseline breathing • No swelling in ankles, feet or legs • No weight gain • No chest pain • Able to do normal activities without difficulty Your symptoms are under control. Continue to take your medication as ordered and weigh yourself daily. Follow your low-salt diet and monitor your fluid intake. Keep all doctor appointments.

My Doctor__________________________________________ Doctor’s Phone _____________________________________

Air Pollution In patients with heart failure, air pollution can reduce the ability of your already weakened heart to pump blood. When there is a lot of air pollution, dust, or pollen outdoors try to stay indoors with the windows closed. You can check the Air Quality Index (AQI) for conditions in your area. Air Quality Index (AQI)

In over 900 counties across the nation, air pollution levels are measured daily and ranked on a scale of 0 for perfect air all the way up to 500 for air pollution levels that pose immediate danger to the public. The AQI further breaks air pollution levels into five categories, each of which has a name, an associated color, and advice to go along with it. You can find the current and forecasted AQI online at: http://www. airnow.gov Index Value

Name

Color

Advisory

0 to 50

Good

Green

None

51 to 100

Moderate

Yellow

Unusually sensitive individuals should consider limiting prolonged outdoor exertion

101 to 150

Unhealthy for Sensitive Groups

Orange

Children, active adults, and people with respiratory disease or heart disease should limit prolonged outdoor exertion

151 to 200

Unhealthy

Red

Children, active adults, and people with respiratory disease or heart disease should avoid prolonged outdoor exertion; everyone else should limit prolonged outdoor exertion

201 to 300

Very Unhealthy

Purple

Children, active adults, and people with respiratory disease or heart disease should avoid outdoor exertion; everyone else should limit outdoor exertion

301 to 500

Hazardous

Maroon

Everyone should avoid all physical activity outdoors.

Heart Failure and Depression

• Crying a lot or feeling sad for weeks at a time

It is not uncommon for people with a chronic disease to experience depression at some point during the course of their disease. Heart failure patients who are depressed have 4 times higher risk of dying and double the risk of being hospitalized as those who are not depressed. Some of the physical changes that you will experience over the course of your disease are breathlessness, weight loss or gain, sleeplessness, and decreased energy. These changes may cause you to experience feelings of loss and can lead to clinical depression.

• Changes in sleeping patterns • Feelings of guilt or worthlessness • Being overly sensitive to criticism • Increased or decreased appetite • Unable to enjoy yourself or find humor in things • Feeling hopeless or suicidal If you think that you may be depressed or are experiencing symptoms of depression, contact your healthcare provider. Your healthcare provider may be able to help. If you are having feelings of harming yourself call 911.

Signs of Depression • Fatigue, lethargy, or lack of motivation

• Memory loss • Difficulty concentrating or making decisions • Feeling irritable or angry towards others

Notes:

SECTION 8

TRAVEL

Traveling by Car • Don’t allow anyone to smoke in the car. Oxygen is highly flammable.

Traveling with Heart Failure Traveling with a heart failure requires advanced planning. 1. You need to make sure that you have enough of your medications to last the duration of your trip.

• Crack the car window. Portable oxygen tanks can give off gasses which may build up in small spaces. • Place your oxygen tank upright beside you. If possible, secure the tank with a seatbelt.

2. Traveling with oxygen poses additional challenges. Using oxygen doesn’t mean you can’t travel, but it does mean that you have to plan ahead.

• Store additional oxygen tanks behind the seat flat on the floor. Never store tanks in the trunk or anywhere that may get too hot.

3. Make sure that you continue to take all of your medications as directed, including diuretics. Diuretics can make travel difficult, but they are an important part of your health care plan.

• Do not leave extra tanks in the car. Once you reach your destination, take extra tanks indoors where they will not be exposed to temperature extremes.

Traveling with Oxygen If you are traveling by car, you may use your own portable tanks or portable concentrator. If you are using other means of transportation, the individual companies may have their own regulations regarding oxygen use. It is important to check with your travel carrier in advance to see if you need to make special arrangements for your supplemental oxygen needs.

• Make sure that you have enough oxygen to last your trip and any travel delays. • If you are using a portable oxygen concentrator, make sure you have extra batteries. Traveling by Bus or Train • Contact your travel carrier 4-6 weeks in advance to see if there are any restrictions on traveling with oxygen. You will probably be allowed to use your own portable tanks or portable concentrator.

Travel Checklist • Notify your healthcare provider of your travel plans. If you have recently been hospitalized, obtain medical clearance before traveling.

• Request seating on a lower level. • Make sure that you have enough oxygen to last your trip and any travel delays.

• If you use oxygen, notify your healthcare provider of your travel plans several weeks in advance. You may need special forms filled out in order to travel with your portable oxygen.

• If you are using a portable oxygen concentrator, make sure you have extra batteries. Traveling by Cruise Ship • Call the cruise line 4-6 weeks prior to your scheduled departure to see if there are any restrictions on traveling with oxygen.

• Notify your oxygen provider of your travel plans several weeks in advance. They can help to arrange oxygen during your travel and when you arrive to your destination.

• Make arrangements with your oxygen provider and cruise line to have tanks delivered directly to the ship before your departure.

• Have copies of current prescriptions, including your oxygen. You may need a letter from your healthcare provider verifying your prescriptions, oxygen, and medical equipment requirements.

• Make sure that you have enough oxygen to last your trip and any travel delays.

• Carry a list of all current medications and doses.

• If you are using a portable oxygen concentrator, make sure you have extra batteries.

• Carry the names and phone #s of your emergency contact person, healthcare provider, pharmacy, and medical equipment provider.

• Plan for medication and oxygen needs for excursions off of the ship.

• Carry all medication and medical supplies in your carry-on luggage. Make sure that you have enough medication, oxygen, and batteries for the entire length of your travel. Plan for delays. 67

Notes:

Traveling by Airplane • Air travel requires an FAA-certified portable concentrator and a form signed by your healthcare provider. Check with the airline and oxygen company at least 2 weeks prior to travel.

• FAA regulations prohibit the use of personal oxygen tanks or liquid oxygen on all commercial airlines. • The airline may be able to provide you with oxygen for in-flight use only. Oxygen will not be provided to cover any time spent in the airport for layovers, changing flights, or delays. You may be charged a fee for using the airline’s oxygen. • Make arrangements with your oxygen supplier before your trip for portable oxygen to use at the airport and once your reach your destination. • Try to get a direct flight whenever possible. • Book your flight as far in advance as possible. The number of seats allotted for oxygen dependent passengers may be limited. • Always reconfirm your oxygen arrangements 4872 hours prior to your departure.

SECTION 9

ADVANCED DIRECTIVES

Advance Directives

3. Anatomical gifts - You may indicate if you would like to donate your organs, eyes, and tissues in the event of your death. You may donate your body for research and education.

Every adult of sound mind has the right to make informed decisions regarding their own health care. It is your health care providerâ&#x20AC;&#x2122;s responsibility to explain any medications, treatments, or procedures that are recommended for your health conditions. If you choose to accept those recommendations, you are giving informed consent. You also have the right to refuse any medications, treatments, or procedures.

In Virginia, an Advance Directive may be filled out without a notary, but the document must be witnessed by 2 people. Any adult may witness the signing of an Advance Directive. Laws regarding Advance Directives may vary from state to state. It is recommended that every adult consider filling out an Advance Directive form. It can save your loved ones from having to make difficult decisions for you and will ensure that you receive the treatment that you would want.

If for any reason you are not able to speak for yourself such as during a serious illness or as the result of an accident, your health care provider would consult family members to make decisions for you. This may involve multiple people and can sometimes result in conflict among family members. An advance directive can help your family and health care professionals to make decisions about your care based on your wishes.

Do Not Resuscitate Order A Do Not Resuscitate Order (DNR) is a document that directs health care providers to withhold life saving treatment (CPR, ventilation, intubation, defibrillation) in the event of cardiac or respiratory arrest. A DNR can only be filled out by a physician, nurse practitioner, or physician assistant and must be signed by the ordering provider and the patient (if a competent adult) or the person authorized to consent for the patient. A DNR does not expire. It is valid unless revoked by the patient or person authorized to consent for the patient.

An Advance Directive is a written document in which you can outline instructions regarding who may make health care decisions for you, treatments that you would or would not want provided, when to withdraw life prolonging procedures, and organ and tissue donation. Things to address when completing an Advance Directive: 1. Appointment of an agent or medical proxy â&#x20AC;˘ This is a person that you would trust to make health care decisions for you if you were not able to make them for yourself

It is important to understand that a Do Not Resuscitate order does not mean that health care providers will withhold all forms of treatment. It means that life saving treatment will not be given if your heart stops or if you stop breathing. You will still be treated for other medical conditions and illnesses.

â&#x20AC;˘ You may name a primary agent (the first person to consult) and a successor (in the event that the primary agent is not available) 2. Health care instructions - You may indicate which life-prolonging treatments that you would like to have. You may indicate at what point, if any, you would like life-prolonging treatments to be stopped:

If you have a life threatening or medically unrecoverable illness such as cancer, end stage disease, or serious injury that you or your health care agent no longer want treated, you may still be given treatments intended to keep you as comfortable as possible until the end of life.

Tube feedings IV fluids Ventilator (breathing machine) Dialysis CPR

Notes:

Chronic Disease Resource Center 540-536-0518 www.valleyhealthlink.com Funded in part by The Winchester Medical Center Foundation