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SP Checkout Script for Congestive Heart Failure and Angina Insights

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SP Checkout Script for Congestive Heart Failure and Angina Insights

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SP Checkout Script for Congestive Heart Failure and Angina Insights

Congestive Heart Failure

What is it? → Heart has some trouble with pumping blood out effectively; blood and fluid may
then back up into the lungs
-S/s of worsening HF: fatigue, congestion, maybe cough, edema legs, SOB
Could you describe to me what your diet is like? → Diet: Na restriction, DASH diet: Eat less fat
and cholesterol, less salt, more fresh vegetable and fruits, lean proteins like fish and chicken,
turkey, whole grains
Common Medications:
- Losartan: works by lowering high blood pressure which can help prevent strokes and heart
attacks
- Digoxin: helps an injured heart pump more efficiently;
- Diuretics (Furosemide/Lasix): aka water pills bc they remove excess fluid from the body to
help you breathe easier and feel better (do not take it after 4pm to lessen the urge to go to
the bathroom during the night)

Introduce yourself
Hello, my name is , and I will be your student nurse today
Wash Hands

Can you tell me your name DOB, thank you!
Name preference
Do you have any allergies
“How would you like to be addressed today”
“I just wanted to inform you that i’ll be writing down some notes today as we speak, so if i’m
looking down that’s why”

Chief Complaint:
What brings you here today?

Hx of Present Illness:
What and where are your symptoms & What triggers your symptoms
O: onset when it started. What were they doing when it started
L: Location; Could you point to where exactly the most pain is?
D: Duration: How long does the pain last for?
C: Characteristic: Can you rate the pain for me on a scale of 0-10; 0 no pain; 10 the worst
- Could you describe if the pain is sharp, dull, does it come and go?

SP Checkout Script for Congestive Heart Failure and Angina Insights

,SP Checkout Script for Congestive Heart Failure and Angina Insights

A: Aggravating Factors: Does anything make the pain worse? With or W/O exercise? Sitting or
standing?
R: Relieving factors: Does anything relieve the pain?
T: Treatment: Have you taken any medications to try and treat the pain?

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SP Checkout Script for Congestive Heart Failure and Angina Insights

,SP Checkout Script for Congestive Heart Failure and Angina Insights




Congestive Heart Failure

What is it? → Heart has some trouble with pumping blood out effectively; blood and fluid may
then back up into the lungs
-S/s of worsening HF: fatigue, congestion, maybe cough, edema legs, SOB
Could you describe to me what your diet is like? → Diet: Na restriction, DASH diet: Eat less fat
and cholesterol, less salt, more fresh vegetable and fruits, lean proteins like fish and chicken,
turkey, whole grains
Common Medications:
- Losartan: works by lowering high blood pressure which can help prevent strokes and heart
attacks
- Digoxin: helps an injured heart pump more efficiently;
- Diuretics (Furosemide/Lasix): aka water pills bc they remove excess fluid from the body to
help you breathe easier and feel better (do not take it after 4pm to lessen the urge to go to
the bathroom during the night)

Introduce yourself
Hello, my name is , and I will be your student nurse today
Wash Hands

Can you tell me your name DOB, thank you!
Name preference
Do you have any allergies
“How would you like to be addressed today”
“I just wanted to inform you that i’ll be writing down some notes today as we speak, so if i’m
looking down that’s why”

Chief Complaint:
What brings you here today?

Hx of Present Illness:
What and where are your symptoms & What triggers your symptoms
O: onset when it started. What were they doing when it started
L: Location; Could you point to where exactly the most pain is?
D: Duration: How long does the pain last for?
C: Characteristic: Can you rate the pain for me on a scale of 0-10; 0 no pain; 10 the worst
- Could you describe if the pain is sharp, dull, does it come and go?
A: Aggravating Factors: Does anything make the pain worse? With or W/O exercise? Sitting or
standing?
R: Relieving factors: Does anything relieve the pain?
T: Treatment: Have you taken any medications to try and treat the pain?

, SP Checkout Script for Congestive Heart Failure and Angina Insights



- Do you have chest pain
- What is your exercise capacity
- Does physical activity aggravate your symptoms
How long ago did this start
How long do your symptoms last
Have you experienced any unintentional weight loss or gain, or a recent decrease in appetite
- Daily weights best indicator of your condition (if you gain 3lb in 2 days, or 5lb over a
week call provider, retaining fluid)


Have you experienced palpitations (fast heartbeat...say this instead of palpitations)
Do you have sleep problems
- Pillows behind back to help sleep, increase HOB → sleeping on an incline can reduce any
congestion in the lungs
Have you had a recent or frequent prior HF hospitalizations
What medications are you taking
Tell me about your diet? Are you on a low sodium diet?
Could you describe to me what your diet is like? → Diet: Na restriction, DASH diet: Eat less fat
and cholesterol, less salt, more fresh vegetable and fruits, lean proteins like fish and chicken,
turkey, whole grains



Does anyone in your family have a history of heart disease?
Do you or your family have any history of strokes or a heart attack?

Do you have any allergies (seasonal, medication, food, etc)
Ask about the reaction

Do you have a hx of any prior surgeries

Are you currently taking any medication
- How long have you been taking this
- Do you feel like it is working for you
- Have you experienced any side effects from it
- Do you remember to take your medication regularly
- Clarify any PRN medications for frequency of use
Do you take anything over the counter including herbals or any vitamins

Does not want to take medications
- It is important that you stay on top of your medications and follow the schedule your

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