Self care of heart failure index V6.2 English

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SELF CARE OF HEART FAILURE INDEX

All answers are confidential.

Think about how you have been feeling in the last month or since we last spoke as you complete these items.

SECTION A:

Listed below are common instructions given to persons with heart failure. How routinely do you do the following?

Never or rarely Sometimes Frequently Always or daily
  1. Weigh yourself?
1 2 3 4
2. Check your ankles for swelling? 1 2 3 4
3. Try to avoid getting sick (e.g., flu shot, avoid ill people)? 1 2 3 4
4. Do some physical activity? 1 2 3 4
5. Keep doctor or nurse appointments? 1 2 3 4
6. Eat a low salt diet? 1 2 3 4
7. Exercise for 30 minutes? 1 2 3 4
8. Forget to take one of your medicines? 1 2 3 4
9. Ask for low salt items when eating out or visiting others? 1 2 3 4
10. Use a system (pill box, reminders) to help you remember your medicines? 1 2 3 4

SECTION B:

Many patients have symptoms due to their heart failure. Trouble breathing and ankle swelling are common symptoms of heart failure.
In the past month, have you had trouble breathing or ankle swelling? Circle one.

0)      No

1)      Yes

11. If you had trouble breathing or ankle swelling in the past month…

(circle one number)

Have not had these I did not recognize it Not Quickly Somewhat Quickly Quickly Very Quickly
How quickly did you recognize it as a symptom of heart failure? N/A 0 1 2 3 4

Listed below are remedies that people with heart failure use. If you have trouble breathing or ankle swelling, how likely are you to try one of these remedies?

(circle one number for each remedy)

Not Likely Somewhat Likely Likely Very Likely
12. Reduce the salt in your diet 1 2 3 4
13. Reduce your fluid intake 1 2 3 4
14. Take an extra water pill 1 2 3 4
15. Call your doctor or nurse for guidance 1 2 3 4
16. Think of a remedy you tried the last time you had trouble breathing or ankle swelling,

(circle one number)

I did not try anything Not Sure Somewhat Sure Sure Very Sure
How sure were you that the remedy helped or did not help? 0 1 2 3 4


SECTION C:

In general, how confident are you that you can:

Not Confident Somewhat Confident Very Confident Extremely Confident
17. Keep yourself free of heart failure symptoms? 1 2 3 4
18. Follow the treatment advice you have been given? 1 2 3 4
19. Evaluate the importance of your symptoms? 1 2 3 4
20. Recognize changes in your health if they occur? 1 2 3 4
21. Do something that will relieve your symptoms? 1 2 3 4
22. Evaluate how well a remedy works? 1 2 3 4
  • Dr. Barbara Riegel

    Dr. Barbara Riegal

    Professor and Edith Clemmer Steinbright Chair of Gerontology
    NewCourtland Center for Transitions and Health
    School of Nursing, Claire M. Fagin Hall
    418 Curie Boulevard
    Philadelphia, PA 19104-4217
    briegel@nursing.upenn.edu
    215-898-9927 Phone
    240-282-7707 eFax