"35*$-& Assessment of patients who present with signs and symptoms suggestive of new onset heart failure or exacerbation of chronic heart failure requires a comprehensive approach as outlined on these cards. Use your “cash” card to insure appropriate assessment of all patients. POTENTIAL CAUSES OF HEART FAILURE: - Coronary artery disease PRECIPITATINg CAUSES OF DECOmPENSATED HEART FAILURE: - Excessive dietary sodium intake
antidysrhythmics (Vaughn Williams Class I)
SIgNS OF HEART FAILURE: - Tachycardia - Third heart sound (S3) - Increased jugular venous pressure - Positive hepatojugular reflux - Bilateral crackles - Peripheral edema not due to venous insufficiency - Laterally displaced apical impulse - Weight gain - Abdominal distention (Note: These signs are generally associated with congestion; not all
patients with acute heart failure are congested). SymPTOmS OF HEART FAILURE: - Dyspnea on exertion - Dyspnea at rest - Orthopnea - Paroxysmal nocturnal dyspnea - Fatigue - Decreased exercise tolerance - Unexplained cough, especially at night - Acute confusion or delirium - Abdominal or gastrointestinal symptoms (e.g. nausea, bloating, abdominal pain, anorexia) - Decreased food intake - Decline in functional status LAbORATORy AND DIAgNOSTIC TESTS ON INITIAL EvALUATION OF HEART FAILURE: - Complete blood count - Urinalysis - Serum electrolytes including calcium and magnesium - Blood urea nitrogen - Serum creatinine - B-type natriuretic peptide - Fasting lipid panel
- Fasting blood glucose - Liver function tests - Drug levels of relevant medications (e.g., digoxin) - Thyroid panel - 1-lead electrocardiogram - Chest radiograph - Two-dimensional echocardiography - Radionuclide imaging (consider) - Cardiopulmonary exercise testing (consider) - Cardiac catheterization (consider) - Myocardial biopsy for suspected myocarditis (consider)
ASSESSmENT QUESTIONS: Symptoms • What symptoms prompted you to seek medical care? When did they begin? • Did your symptoms begin suddenly or gradually worsen over time? • What makes the symptoms better/worse? • Do the symptoms occur continuously or only with certain activities? • Do symptoms improve with rest? • Do you have any pain now? Did you recently have pain? Rate on a 0-10 scale. • Has your heartbeat felt any different than usual? E.g., “race,” “flutter,” or “skip?” breathing • Have you felt short of breath? Do you wake up short of breath at night? • Can you speak as much as you like before getting short of breath? • What makes your breathing easier? • Do you cough? Is it worse than usual? • Do you cough throughout the day or mostly in the morning? • Do you cough up any secretions? • Do you use oxygen at home? Sleep • Have symptoms kept you from sleeping? • Do you sleep in bed or in a chair? • Are you able to lie flat in bed?
• How many pillows do you use to sleep? Is this more or less than usual? • Have you recently slept more or less than usual? Do you feel rested?• Ask spouse/significant other if patient snores or intermittently stops breathing during sleep. Diet • Have you recently eaten more salty foods or drank more water than usual? • How often do you eat out? • How often do you weigh yourself? • Have you gained or lost weight recently? • Have you experienced any swelling? Is swelling present all day or only evenings? • How far up your legs do you have edema? • Have you felt bloated or had edema? • Are your clothes, belt, rings, and shoes tighter than 1 week or 1 month ago? • Have you had nausea or abdominal pain? medications • Have you taken all prescribed meds? • Did you run out of any medications? • Have you had diarrhea/vomiting that may have affected absorption of medications? • Have you taken extra diuretic meds? • Have you changed the dose of any med? • Did any physician/NP recently prescribe different medications for you or change the dose
• Do you take any over-the-counter medications or herbal supplements?
Activity • How far can you walk? • Can you dress, bathe, prepare food, climb stairs without stopping to rest? • What activities could you do recently but not now because of worsened symptoms? • Have you decreased your activity level? Other • Do you have difficulty remembering information or feelings of confusion? • Have you had other health problems that may make your heart failure worse?
2006 American Association of Heart Failure Nurses
COAMATIC® Protein C - 82 2098 63 ENGLISH - Insert revision 12/2002 Intended use Specimen collection Calculation This kit is for the quantitative determination of Protein C activity in human citrated plasma. Nine parts of freshly drawn venous blood are collected into one part trisodium citrate. Plot the absorbance (A) for the standard samples against their protein C activity on B
Effective January 1, 2008 2008 EMPIRE PLAN PREFERRED DRUG LIST Administered by UnitedHealthcare The following is a list of the most commonly prescribed generic and brand-name drugs included on the 2008 Empire Plan Preferred Drug List. This is not a complete list of all prescription drugs on the preferred drug list or covered under the Empire Plan. This list is subject to change du