Download GOALS FOR CONGESTIVE HEART FAILURE SELF MANAGEMENT

GOALS FOR CONGESTIVE HEART FAILURE SELF MANAGEMENT
Goal
Goal 1
Goal 2
Goal 3
I will call my doctor as soon as I notice signs of my heart failure
becoming worse such as gaining more than 2lbs in weight in 24 hours
or becoming more short of breath
Date
I will take all the medicines ordered by my doctor and remind myself
by:
___Keeping the medications in a pill box.
___Writing out a list of what I need to take, how much and when
I will keep an updated list of all the medications I take and bring the
list with me when I see my doctor.
Date
I will follow a low salt diet by__Not adding salt to food when I cook __Not adding salt to food I
eat__Using a salt substitute__Reading food labels
Date
I will weigh myself every day and write it down. If I have gained
weight, I will follow my doctor’s advice and increase my water pill as
instructed. I will keep my doctor informed.
Date
I will get a flu shot this fall and get a pneumonia vaccine if I haven’t
had one done
Date
I will reduce the amount of fatty foods I am eating now by:
Eating more fruits____salads____vegetables_____lean meats____
Date
I will work on quitting smoking. I will be down to ___cigarettes a
day by my next visit to the doctor
Date
I will limit alcoholic drinks to no more than 2 - 3 drinks each week.
Date
I will exercise ____days a week for___ minutes ___days a week
The exercise I choose to do is:
Date
I will keep my fluid intake down to ______a day.
Date
Date
Goal 4
Goal 5
Goal 6
Goal 7
Goal 8
Goal 9
Goal 10
Goal 11
Source: Kosciusko Community Hospital, Warsaw, IN. (KCH – patient self-management)
Adapted by CP for CPSI