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    CHF Stop Light Tool

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    keerplunk369
    chf

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    © All Rights Reserved
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    CHF Stop Light Tool

    Uploaded by

    keerplunk369
    3 views1 page
    chf

    Original Title

    CHF STOP LIGHT TOOL

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    © © All Rights Reserved

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    chf

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3 views1 page

    CHF Stop Light Tool

    Uploaded by

    keerplunk369
    chf

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Heart Failure Self-Management Plan

    Name _____________________________________________________ Date _______________________________


    Every day: Weigh yourself in the morning Take your medications Eat low salt foods Balance activity with rest periods

    Green Zone: All Clear What this could mean:


    If you have: Your symptoms are under control
    No shortness of breath
    Continue to take your medications as ordered
    Weight gain less than two pounds
    (although a 1–2 pound gain may occur some days) Follow healthy eating habits
    No swelling of your feet, ankles, legs, or stomach Keep all physician appointments
    No chest pain
    Ability to do usual activities

    Yellow Zone: Caution What this could mean:


    If you have any of the following: Your symptoms may indicate that you need an adjustment of your
    A weight gain of two or more pounds in one day or 3–5 medications
    pounds in one week Call your home care nurse or primary care doctor and your cardiologist
    Increased shortness of breath
    Doctor: _____________________________________________
    Increased swelling of your feet, ankles, legs, or stomach
    Fatigue or lack of energy Phone: ______________________________________________
    Dry hacking cough Instructions: __________________________________________
    Dizziness
    Cardiologist: _________________________________________
    An uneasy feeling—you know something is not right
    Difficulty breathing when lying down or you sleep sitting Phone: ______________________________________________
    up with extra pillows Instructions: __________________________________________
    New or frequent chest pain or tightness
    If you notice a Yellow Zone Caution, work closely with your healthcare team

    Red Zone: Medical Alert! Stop and Think What this could mean:
    If you:
    Are struggling to breathe or have unrelieved You need to be evaluated by a healthcare
    shortness of breath while sitting still professional immediately
    Have chest pain not relieved or reoccurs after
    taking three nitro tablets
    Call 9-1-1
    Have confusion or can’t think clearly Notify your healthcare provider’s office
    This material was prepared by Aging and Disabilities Services and adapted for use with permission by Health Services Advisory Group, the Medicare Quality Innovation Network-Quality
    Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
    Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-C.3-11062018-04

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