PALOMAR POMERADO HEALTH SPECIALIZING IN YOU Living Successfully

PALOMAR POMERADO HEALTH SPECIALIZING IN YOU Living Successfully with Heart Failure HMJ1 12.07 1

Table of Contents Welcome 3 Contact Information 4 Introduction 5 What is Heart Failure? 6 What Causes Heart Failure? 7 Other Questions to Ask 8 How Does it Feel to Have Heart Failure? 10 What Should Concern Me? 11 Taking Care of Yourself 12 Weigh Yourself Daily 13 Take Your Medications Exactly as Directed 14 Types of Medications 15 It Helps to Eat Food High in Potassium and Low In Sodium 18 Follow a Low Sodium Diet 19 Herb Seasoning Suggestions 20 Dining Out 21 Guidelines for a 2 gram (2000 mg) Sodium Diet 22 Reading Food Labels 23 Sample Food Label 24 Avoid Drinking Too Much Fluid 25 Limit Alcohol 26 Stop Smoking Now 27 Relapse Prevention for New Non-smokers 28 Know Your Diabetes Risk 29 Get regular Exercise 30 Exercise Routines 31 Exercise Smart 32 Suggestions for Energy Conservation 34 Activities of Daily Living 35 Make This Plan a Permanent Part of Your Life 39 Notes 40 Home Medication Log 44 Daily Weights 48 2

Welcome to Palomar Pomerado Health (PPH). The mission of PPH is to heal, comfort, and promote health in the communities we serve. Our vision is that PPH will be the health system of choice for patients, physicians, and employees and be recognized nationally for the highest quality of clinical care and access to comprehensive services. Our goal is to provide you with excellent healthcare. Our visiting policy is individualized and flexible based on the needs of our patients and family members. The packet you are receiving has general information you may find helpful in dealing with your condition, or your loved one’s condition. Additional handouts will be given to you for any other risk factors that may be present. Handouts are available for medications you may be taking or will take at home. These handouts will be given to you when you are admitted and others may be added before you go home. Your nurse or your primary healthcare provider can answer any questions you may have. We encourage you to write down your questions or comments on the “Notes” pages provided at the back of this booklet. Please use these pages to speak to your nurse or primary healthcare provider about anything regarding your hospital stay with PPH. We want your experience to be as pleasant as possible. If we can help you with anything, please do not hesitate to ask. For any questions, comments, or concerns, please call the nurses’ station directly for immediate assistance. Palomar Medical Center All prefixes are: 1-760-739 Surgical, 8th Floor: 3840 Medical/Oncology, 7th Floor: 3740 Intermediate Care, 7th Floor: 3790 Telemetry, 6th Floor: 3640 Critical Care, 6th Floor: 3655 Orthopedic/Stroke, 5th Floor: 3540 Pomerado Hospital All prefixes are: 1-858-613 Medical/Surgical/Telemetry, 4th floor: 4440 Medical/Surgical/Telemetry, 3rd floor: 4340 Critical Care/Intermediate Care, 2nd Floor: 4339 3

Contact Information Please write down important contact information in the spaces below. You may want to share this information with family members and friends. Doctor Treating Me for Heart Failure Name: Address: City: State: Zip code: Phone number: Other Important Phone Numbers – Ambulance, fire department, or emergency services: 911 Pharmacy: Other doctors or nurses: 4

Introduction Many people with heart failure lead normal, active lives. They do so because they have learned to take good care of themselves. This book is designed to help you learn to live successfully with heart failure. We want you to learn about your body, the disease, and methods of treatment. You can take control over heart failure by carefully following proper medication advice and healthy lifestyle changes. If you do so, you too may be able to lead an active and satisfying life! This booklet provides basic information on heart failure. It will help you: Understand your treatment plan Learn how to actively work with your doctor or nurse so you can feel better Learn how to overcome common stumbling blocks in following your treatment plan 5

What Is Heart Failure? Many people misunderstand exactly what heart failure means. Heart failure does not mean that your heart has stopped or is about to stop. Heart failure is a serious illness in which the heart doesn’t pump blood through your body as well at it should. Your heart still beats, but it pumps less nutrient-and oxygen-rich blood to the rest of your body. Because of this, heart failure can make you feel tired or weak. Heart failure can also cause swelling and fluid buildup in your legs, feet, and even your lungs. Fluid backing up into the lungs is often referred to as “congestion,” which is why heart failure is sometimes called “congestive heart failure” or CHF. 6

WHAT CAUSES HEART FAILURE? What Causes Heart Failure? Heart failure usually occurs when another problem makes the heart weak or stiff so it doesn’t pump or fill normally. Coronary artery disease is a common cause of heart failure. Other causes include previous heart attack, high blood pressure, infection of the heart muscle, lung disease, and problems with the heart valves. Ask your primary healthcare provider what causes your heart failure. There may be special things you can do to care for yourself that are not included in this booklet. The cause of my heart failure is: 7

Other Questions to Ask Asking questions can help you talk about heart failure with your doctor or nurse. Talking with your healthcare providers will help to ensure you are receiving the best possible care. Your health is an active partnership between you and your doctor or nurse. Do I have blockages in my coronary arteries? Reason for asking this question: Coronary artery disease is a common cause of heart failure. With this disease, blockages in the coronary arteries decrease or cut off the blood supply to portions of the heart muscle. It can be possible to open the blockages and restore blood supply to the heart. This can improve heart function and reduce your symptoms. Knowing if your heart failure is a result of blocked coronary arteries can help your doctor plan the best treatment for you. Is my blood pressure high? Is my blood pressure under control? Reason for asking this question: High blood pressure is a cause of heart failure and it can make heart failure worse. Reducing blood pressure to normal levels is a way to reduce strain on the heart. It is important to know whether your blood pressure is under control. Your doctor can help to make sure it is managed well. Are my heart valves damaged? Reason for asking this question: Heart valve damage is a cause of heart failure. Sometimes, valve damage can be repaired so that heart failure improves. 8

Other Questions to Ask What is my heart function (ejection fraction or “EF”)? Reason for asking this question: Heart function is commonly assessed by using a number call the ejection fraction. The ejection fraction is not a number of the amount of heart muscle that is still working rather it refers to the percentage of blood that is pumped out of the heart each time it beats. A heart will not pump out all of the available blood with each beat. A normal heart pumps out, or ejects, about 5065% of the blood inside. If the heart is damaged, the ejection fraction can fall below 40%. This is called systolic heart failure. You can have a normal ejection fraction and still have heart failure. This can be related to a condition called diastolic heart failure. An echocardiogram is commonly used to evaluate heart function. The test can tell you and your doctor about your heart and heart valve function. It is important to know your heart function because it can help to determine the severity of heart failure. It will also help to guide your care. Once your primary healthcare provider has evaluated your heart function, it is not necessary to keep testing it. 9

How Does it Feel to Have Heart Failure? People with heart failure often have the following symptoms: Shortness of breath, wheezing or coughing with activity Weakness or tiredness Problems with breathing when lying down Waking up at night coughing or short of breath Swollen ankles, legs, belly, and/or feet Increased heart rate, or heart palpitations Loss of appetite Weight gain 10

What Should Concern Me? Just because symptoms are common does not mean you should ignore them! Call your primary healthcare provider for any of the following: Increased ankle swelling Problems breathing at night Weight gain or loss of 2-3 pounds in 2-3 days or 4 pounds in a 7 days or less A change in your ability to sleep An increase in coughing, wheezing, or shortness of breath Increasing fatigue Decreasing ability to be active Nausea and/or loss of appetite CALL 911 IMMEDIATELY if you have any of the following: Prolonged chest pain that does not respond to nitroglycerin. Extreme shortness of breath or trouble breathing. Feel like passing out. You feel your pulse is irregular or rapid or feel a fluttering in your chest (palpitations). 11

Taking Care of Yourself The treatment of heart failure typically involves several steps. The steps are listed here and explained more later in this booklet. Weigh yourself daily Take your medications exactly as directed Follow a low sodium diet Avoid drinking excess fluids Avoid alcohol consumption Maintain a normal body weight Get regular exercise Know the warning signs of heart failure Stop Smoking Keep follow-up appointments Make this plan a permanent part of your life 12

Weigh Yourself Daily A sudden weight gain is one sign that you are retaining fluid. Weigh Yourself: At the same time every day (preferably first thing in the morning) Without clothes or in lightweight clothing After you urinate Before you eat breakfast Write your weight down every day for your records. Bring your record with you when you visit your doctor If you have a weight gain or loss of 2-3 pounds in 2-3 days OR 4 pounds in 7 days or less, call your primary healthcare provider. * “Daily Weights” sheets are provided at the back of this booklet for your convenience. 13

Take Your Medications Exactly as Directed Medications typically given for heart failure include: Blood vessel dilators (ACE inhibitors, beta blockers and many others) Diuretics/water pills Aldactone, Spironolactone Potassium Supplements Heart strengtheners (Digoxin, Lanoxin or Digitalis) * “Medication Schedule” sheets have been provided at the back of this booklet for your convenience. Use the sheets to keep track of the medications you take, how often you take them, why you take them, and if there are any special instructions for taking them given to you by your primary healthcare provider. Blood vessel dilators can be ACE inhibitors, beta blockers, or others. Blood vessel dilators make the blood vessels relax so it is easier for the heart to pump blood into vessels. Ask your nurse or pharmacist for detailed instructions on the medications you are given. 14

Type of Medications ACE inhibitors work much like the other blood vessel dilators. Common ACE inhibitors include Capoten (Captopril), Vasotec (Enalapril), Zestril (Lisinopril) and Altace (Ramipril). These drugs help to keep your heart failure from getting worse. Sometimes they even shrink an enlarged heart back to normal size. No matter how well you feel, do not stop taking this medication without your primary healthcare provider’s advice. Beta blockers are other drugs that relax the blood vessels and also relax the heart, possibly lessening the stress which may play a part in the heart failure. Common beta blockers include Carvedilol (Coreg) or Metoprolol (Toprol XL or Lopressor). They are used in stable patients and in combination with water pills and other blood vessel dilators. Some patients may initially gain weight, have swollen ankles, or shortness of breath. NOTIFY your primary healthcare provider if this happens. Some patients feel slightly weak or dizzy at first; this effect usually goes away within a few days. Other vasodilators include Norvasc, Isordil, Apresoline, Minipress, Sorbitrate, and others. 15

Type of Medications Diuretics are water pills that help your kidneys produce more urine. This results in less fluid for your heart to pump. With less to pump, the heart does not need to work so hard. Commonly prescribed water pills include Furosemide (Lasix), Bumex (Bumetanide), Zaroxolyn (Metolazone), Hydrodiuril (HCTZ), and Diuril (Chlorothiazide). Along with an increase in urination, you may feel thirsty. Thirst and urination are normal effects of diuretics. Do call your primary healthcare provider if you are taking diuretics and experience: Dizziness Severe weakness Severe leg cramps Potassium supplementation helps to control your heart rhythm. Potassium is a mineral that your body needs. Some water pills cause you to lose potassium (KCL) along with urine. If this happens, you may need to take extra potassium. It is often prescribed in tablet, liquid, or powder form. The liquid or powder forms should be mixed in 3 to 4 ounces of fruit juice or water to avoid stomach upset. Liquid potassium is salty and bitter. Do not let the taste keep you from taking this essential medicine! 16

Type of Medications Aldactone or Spironolactone are aldosterone antagonists (hormone blockers). This medication may be started in a low dose and increased gradually. Blood potassium and creatinine (for kidney function) will be closely monitored the first few weeks of therapy and then on a regular basis after that. Your doctor may take you off all potassium supplements if you are on this medication. Digoxin (Lanoxin) is medicine that strengthen the heart muscle help assure that more blood is pumped with each beat. Digoxin, a commonly used heart strengthener, is usually taken once daily. Call your primary healthcare provider if you feel any of these possible side-effects: Loss of appetite, distaste for food or bad taste in the mouth Nausea or vomiting Bluish or yellowish vision Skipped heart beats, dizziness, palpitations, or rapid heart beating 17

It Helps to Eat Food High in Potassium and Low In Sodium Dried fruits (raisins, prunes, apricots, figs, dates) Fresh fruits (bananas, cantaloupe, grapes, oranges, honeydew melon, fruit juices) Fresh vegetables (avocados, potatoes, beets, greens, spinach, peas, tomatoes, mushrooms) Dried vegetables (beans, peas) Fish (flounder, halibut) Fresh meats (turkey, beef) Decaffeinated coffee 18

Follow a Low Sodium Diet Getting Started: A moderate 2 gram (2000 mg) per day diet restriction is essential Ask your primary healthcare provider how much sodium you can eat. Table salt contains 40% sodium and 60% chloride, so use it sparingly. One teaspoon of table salt contains about 2300 mg of sodium! Sodium is a naturally occurring ingredient in almost all foods. Fresh, unprocessed foods are naturally low in sodium. High amounts of sodium are found in many canned, pickled, convenience, packaged, processed and “fast” foods. Give yourself time to adjust to reduced sodium in your diet. Remember, salt is an acquired taste and it can be unlearned. Be patient and learn to enjoy new flavors in foods. Salt Substitutes: There are two basic types of salt substitutes, the “herb” type and “potassium chloride.” It is important to know the difference because some people should avoid the potassium chloride salt substitute (common brand names being NuSalt or NoSalt). You should discuss use of potassium chloride (or KCl) as a salt substitute with your primary healthcare provider before using it. This compound may act as a strong drug for some people. On the other hand, herb seasonings can be enjoyed by almost everyone. 19

Herb Seasoning Suggestions Beef Curry, basil, bay leaf, dill, mustard, onion or garlic, mushrooms, sage, tarragon, thyme, grape, nutmeg, parsley, pepper. Chicken Cloves, pineapple, paprika, sage, tumeric, oregano, cranberry. Fish Dill , curry, lemon rind and lemon juice, tomato, ground pepper, chervil. Pork Cloves, applesauce, caraway, rosemary, thyme, chives, basil, onion or garlic. Eggs Paprika, tarragon, parsley, onion, jelly, curry, chervil, tomato, mushrooms. Vegetables Garlic or onion, basil, dill, green pepper, unsalted salad dressing, vinegar, tomato, mushroom, mint, mace. Desserts Vanilla, extracts of other flavorings, mace, nutmeg, cinnamon, ginger, allspice. Spice blend recipe 1 tsp chili powder 2 tsp ground oregano 2 tsp black pepper 1 T garlic powder 3 T paprika 6 T onion powder 3 T poultry seasoning 20

Dining Out Here are some suggestions for reducing sodium when eating in restaurants: Choose foods without sauces or ask for the sauce on the side so you can control the amount you eat. Patronize those restaurants where food is cooked to order. Ask your server for chopped onions, chives, lemon, or other fresh herbs to use as flavorings. Frequent authentic ethnic restaurants. They often use fresh ingredients for flavor instead of relying on salt and processed (salt laden) foods. Ask the server to suggest some low salt alternatives. Choose ala carte and pick the most simple foods such a plain green salad, baked potato, etcetera. Carry your own herb seasoning blend with you. Suggestions For Reducing Sodium In Your Diet: Eat fresh fish, meats, vegetables and fruits. Avoid convenience foods like soup, frozen or canned prepared main dishes such as “TV” dinners, ravioli, pot pies, pizza. Avoid sausages, luncheon meats, hot dogs, ham, bacon, and other cured or smoked meats, poultry and fish. Don’t cook with salt or add salt to your food at the table. Season with lemon, onions, spices and herbs such as pepper, paprika, curry, or dill. Avoid seasoned salts like garlic salt and onion salt. Use “Low Sodium” or water-packed canned vegetables, or rinse and drain regular canned vegetables before cooking. Avoid hidden sources of sodium such as soy sauce, steak sauce, teriyaki sauce, barbecue sauce, monosodium glutamate (MSG), and meat tenderizers. Avoid pickled foods or foods packed in brine such as relish, pickles, sauerkraut. Avoid salty snacks such as corn or potato chips, salted nuts, salted crackers. 21

Guidelines for a 2 gram (2000 mg) Sodium Diet Food Groups MILK Suggested Daily Servings Limit to 3 cups per day (1 cup 8 oz.). VEGETABLES Unlimited fresh, frozen, and low-sodium canned vegetables BREAD Limit to 5 servings per day (1 serving 1 slice bread or 1 dinner roll). If you eat more than 5 servings per day, switch to “Low Sodium” bread. Avoid all quick breads such as biscuits, pancakes, waffles and corn bread; self-rising flours; stuffing mixes; regular bread crumbs; breads/rolls/crackers with salted tops. PASTA/RICE/BEANS Unlimited. Avoid commercially prepared rice & pasta mixes. CEREALS Unlimited unsalted cereals such as cooked cereals (non-instant) and puffed wheat or rice. FRUIT Unlimited fresh, frozen or canned. MEAT/POULTRY/ EGGS/EGG SUBSTITUTE 6 oz. per day (1 egg 1 oz. Meat) MISCELLANEOUS: Crackers, popcorn, pretzels, nuts. Unsalted only, peanut butter, cheese, butter, margarine. SOUP Low sodium only. CARBONATED BEVERAGES Limit to no more than 50 mg. sodium per day from this source. DESSERTS Limit desserts (cake, cookies, pie, etc.) to 1 to 2 servings per day. 22

Reading Food Labels It is important that you read food labels to determine the sodium content of foods. Sodium content is expressed in milligrams (mg) per serving. It may also be helpful to know that certain words used on labels must mean what they say as defined by the government: Key Words Meaning “Sodium Free” negligible sodium (less than 5 mg per serving) “Very Low Sodium” 35 mg sodium or less per serving “Low Sodium” 140 mg sodium or less per serving “Less Sodium” 20% sodium reduction from the original product “Reduced Sodium” at least 25% reduction from the original product “Light in Sodium” 50% sodium reduction from the original product “Unsalted” “Without Added Salt” “No Salt Added” no salt used during processing 23

Serving Size Always keep the serving size in mind when you inspect the label because all of the nutrient categories are based on this. Nutrition Facts Serving Size 1/2 cup (114g) Servings Per Container 4 Amount Per Serving Calories Total kilocalories per serving Calories 90 Calories from Fat 30 % Daily Value* Total Fat 3g Total Fat Total grams (g) fat per serving. Try to limit fat calories unless you have trouble gaining or maintaining your weight. Always try to limit saturated fat, especially if you need to lower your blood cholesterol level. 5% Saturated Fat 0g 0% Cholesterol 0mg 0% Sodium 300mg 13% Total Carbohydrate 13g 4% Dietary Fiber 3g Sodium Total milligrams (mg) sodium per serving. This is salt! The chemical name for “salt” is “sodium chloride”. This label tells you that a 1/2 cup serving contains 300 mg of sodium. Remember to limit your daily total to no more than 2000 mg to 3000 mg. 12% Sugars 3g Protein 3g Vitamin A Calcium 80% Vitamin C 60% 4% Iron 4% *Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs: Calories 2,000 2,500 Total Carbohydrate Total grams (g) of carbohydrate per serving. Sub-categories identify the amount of added sugars and nutritionally important dietary fiber. Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg Total Carbohydrate 300g 375g Fiber 25g 30g Calories per gram: Fat 9 Carbohydrate 4 Protein 4 Protein Total grams (g) protein per serving. Choose the lean sources of animal protein such as lean red meat, poultry, fish and fat-free or lowfat milk. Or, try vegetable protein sources such as beans, cereals and grains. 24

Avoid Drinking Too Much Fluid Most people with heart failure can drink normal amounts of fluid. Do not restrict your fluids unless specifically told to do so by your primary healthcare provider. But, everyone with heart failure should avoid excess fluids; try around 48oz – 64oz or 1.5 – 2 liters a day. Drink fluids at intervals throughout the day Avoid drinking large amounts of fluid all at once 25

Limit Alcohol Consumption As a general rule, you should not drink alcohol at all. It damages heart cells and can further weaken your already-weak muscles. Any alcohol use is strongly discouraged. Ask your primary healthcare provider what is right for you. 26

Stop Smoking Now Smoking can make heart failure worse, so if you smoke, you should stop immediately. Quitting takes hard work and a lot of effort, but you CAN quit smoking. For counseling or to register for PPH Kick the Habit Program, please call the Cancer Resource Center at (760) 739-3943 or (858) 613-4044. 27

Relapse Prevention for New Non-smokers Think of yourself as a non-smoker. Decide that cigarettes, or any tobacco products, are not an option! Refer to yourself as a non-smoker, not as an ex-smoker Watch out for the top 3 triggers. Being around smokers Alcohol Highly emotional situations – (Remember to watch yourself for your personal triggers as well.) You can manage your weight when you quit. Stay active Drink water and eat healthy meals Keep low-fat, low-calorie snacks on hand – (Remember to follow the specific dietary or fluid guidelines and/or restrictions that your primary healthcare provider has discussed with you.) You can manage stress when you quit. Incorporate stress reducing activities in your new lifestyle Use stress management techniques If you “slip” (smoke or use tobacco products), do not let it turn into a relapse. Ask yourself what went wrong Fine tune your strategies and recommit to quitting One cigarette does not mean that you are a smoker again! If you have a relapse, you can get back on track. Ask yourself if you still want to quit Find a NEW reason to quit Revise your strategies, commit to quit, and set a new date Join, or rejoin, a support group to help you stay a non-smoker For more information, or to register for PPH Kick the Habit Program, contact the PPH Cancer Resource Center at 760.739.3943 or 858.613.4044. 28

Know Your Diabetes Risk Type Two Diabetes Mellitus (Type 2 Diabetes) is a metabolic disorder characterized by the body’s inability to produce enough insulin and or the body cells being resistant to insulin. Therefore, there is an abnormal elevation of blood sugar. Why should I be concerned to know if I have Type 2 Diabetes? Type 2 Diabetes rarely occurs alone. People that are newly diagnosed with Type 2 Diabetes usually already have a disease such as High Blood Pressure and/or Abnormal Cholesterol levels. High blood sugar is not just high blood sugar. If left untreated, high blood sugar will harm large and small blood vessels – every cell of your body is affected. What are the risk factors of Type 2 Diabetes? Diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, and Pacific Islanders (however, Type 2 Diabetes is seen across all race / ethnic groups). Age over 45 (the older one gets the higher the risk – however children as young as 8 years of age are being diagnosed with Type 2 Diabetes). First-degree relative (sibling or parent) with Type 2 Diabetes. Overweight, especially being overweight around the ‘belly’ (apple shape). Sedentary (inactive) lifestyle. Women who had gestational diabetes or gave birth to at least one baby weighing more than 9 pounds (if your mother had gestational diabetes while pregnant with YOU, you are at risk). Having other health problems such as: High Blood Pressure, Abnormal Cholesterol, and other Cardiovascular Diseases. Other co-existing factors that could increase your risk – smoking, continual high stress levels, and depression. The more risk factors you have, the more at risk you are of developing or having Type 2 Diabetes. Don’t Ask – Don’t Tell – Absolutely NOT! Uncontrolled diabetes is the leading cause of blindness, renal failure, and limb amputations (not associated with injuries). The leading cause of death in the United States is heart disease (68% of these people had diabetes). Two out of three people with diabetes die from heart disease and stroke. It is estimated that once a person is diagnosed with Type 2 Diabetes, he or she likely had diabetes for at least 5 to 7 years before being diagnosed. Ask Your Primary Healthcare Provider for Further Evaluation to See If You Have Diabetes or Are at Risk. Prevention and Early Diagnosis and Treatment To help Prevent the Complications of Uncontrolled Diabetes is Crucial! For more information, contact PPH Diabetes Health at 760.739.2865 or 858.613.4164. 29

Get Regular Exercise We used to believe that people with heart failure should rest, rest, rest. Now we know that regular exercise is essential! Even short periods of bed rest cause weakness. Research shows that you can exercise safely. Remember to talk to your primary healthcare provider first before starting an exercise program. Along with prescribed medication, exercise will: Help you feel better – stronger and with less breathing trouble. Help you to walk farther, work or shop with less fatigue and enjoy fun activities longer. Help you sleep better at night. Help maintain and/or improve your balance and help prevent falls. Help you lose weight if needed. Help you feel more positive and confident. Help you relieve some stress. Which type of exercise is the best? The best exercise for your heart is “aerobic” exercise. Pick activities that are continuous and have a smooth flow: Walking Riding a bicycle (stationary or regular) Swimming Water exercise or walking in a pool Plan to do different things in different settings so you have fun and stay interested! 30

Exercise Routines How much exercise is enough? Start off slowly. Increase the time and level of activity gradually. Remember that any time you spend a day or more in bed or in the hospital, you will be weaker than usual. Let your body be your guide. How long should I exercise? Start with 2-5 minutes of easy walking. Rest for 2-5 minutes. Then do 2-5 minutes more of easy walking. As you become stronger, gradually increase your walking time. Keep your rest time at 1-2 minutes. Keep doing this until your total exercise time is about 20 minutes. When you can walk for 20 minutes without stopping, slowly increase your walking time to 30-40 minutes. If you start having trouble breathing or feel worn out, you have done too much. Stop, rest, and make sure to do less the next time. You don’t have to do all of your activity at once either. For example, you can go on two short walks instead of one long one. How often should I exercise? Try to exercise 4-6 days each week if you feel well. Make exercise a part of your daily routine, like daily weights and taking your medicines. The key is to get moving as many days as you can. How hard should I exercise? Keep your effort light and comfortable. You should be able to walk and talk at the same time. If you have trouble breathing or feel worn out, you are doing too much. Do not push yourself. 31

Exercise Smart Listen to your body. Rest when you are tired, relax when you are under stress, and let your healthcare team know when you are not feeling well. Choose activities that you enjoy. Exercise with a buddy if you can. As you exercise, stay “slow and steady.” Avoid activities that require a quick burst of energy. Keep your effort light to moderate. If you exercise shortly after taking your medicines, you may become dizzy or faint. A change in timing of exercise will often relieve this problem. Avoid extreme heat or cold. If it is hot or humid out, move your workout indoors to a cooler time of the day. Walk in a shopping mall or follow an exercise video at home (pick an easy one). Drink enough fluids to stay hydrated depending on your fluid allowance. Any time of the day is fine for exercise. But wait at least two hours after a large meal. Also, do not exercise if you have not eaten for a long time. A light meal 12 hours before exercising is ideal. If you get tired easily, walk on flat ground when possible. Dirt or cinder walking tracks, grass playing fields, parks, nature trails, and golf courses are wonderful for walking. Wear loose fitting clothes and comfortable walking shoes. Running shoes may be easier on your feet. Before you exercise, “warm up” for a few minutes by doing your activity at a slow pace. This will help blood flow to your muscles and ease you into the exercise. After the warm up, do some stretching. This will keep your muscles flexible and lower your risk of injury. After you finish your exercise, ease into a “cool down” phase. Do this by repeating your warm up routine for a few minutes. Always allow some time after your activity to rest and relax. 32

Exercise Smart Skip exercise any day that: You are not feeling well. You have had a weight gain over 2-3 pounds in 2-3 days or 4 pounds in 7 days or less. Be sure to call your primary healthcare provider if this happens. You have unusual ankle swelling or bloating in your stomach. You are having more trouble breathing, or are coughing or wheezing. Stop exercising immediately if you feel any: Pressure or pain in your chest, neck, arm, jaw or shoulder. Dizziness, lightheadedness or nausea. Unusual shortness of breath. Unusual tiredness. Heartbeat that feels unusual - too fast, too slow, or feeling like your heart is “skipping a beat.” Any other symptom that causes you concern. Call your healthcare provider for: Shortness of breathing lasting 10 minutes or more. Dizziness or lightheadedness. Chest pain. Nausea, vomiting or cold sweat. *Remember to speak with your primary healthcare provider first before starting an exercise program. 33

Suggestions for Energy Conservation Plan Ahead and Organize Your Work – change storage of items to reduce trips or reaching – delegate when needed – combine motions and activities and simplify details Schedule Rest – balance periods of rest and work – rest before fatigue – frequent, short rests are beneficial Pace Yourself – moderate pace is better than rushing through activity – reduce sudden or prolonged strains – alternate sitting and standing Practice Proper Body Mechanics – when sitting, use well-supporting chair – adjust work heights-work without bending over – bend at knees and hips, not at back – carry several smaller loads or use a cart Limit Overhead Work – use long handled tools – store items lower – delegate Limit Isometric Work – breathe evenly, do not hold your breath Identify Effects of Your Environment – avoid extremes of temperature – eliminate smoke or noxious fumes – avoid long, hot showers or baths Reduce Stress – learn relaxation techniques – physical exercise reduces stress – anticipate fatigue and stress and plan ahead to reduce stress Prioritize – decide what activities are important to you, and what could be delegated – use your energy on important tasks 34

Suggestions for Energy Conservation: Activities of Daily Living Washing & Bathing – Wash hair in shower, not over sink – Sit and use a terry robe instead of drying off with a towel – Use a shower organizer over the shower head to avoid leaning and reaching – Use safety strips on the floor of the tub – Install a grab rail – Use a shower bench or lawn chair to sit while showering – Use a handheld shower while sitting – Use moderate temperature water rather than hot – Use a long-handled sponge or brush to reach feet and back Grooming/Hygiene – Sit when grooming – Don't lean forward unsupported – Rest elbows on counter or dressing table – Use long-handled brushes or combs to avoid holding arms overhead – Use elevated commode seat Dressing – Loose fitting clothes allow you to breathe more easily – Organize early so you won't have to rush – Lay out clothes before starting, to avoid extra steps – Bring your foot to your knee to apply shoes and socks so you won't have to lean over – Wear slip-on shoes – Use a long-handled shoe horn and sock aid – Fasten bra in front and then turn to back – Wear button front shirts rather than pullovers – Use a reacher and/or a dressing stick 35

Suggestions for Energy Conservation: Activities of Daily Living Doing Laundry – Use a laundry cart on wheels – Use an automatic washer and dryer if possible – Sit to transport clothes to the dryer if possible – Use a commercial pre-wash instead of scrubbing – Wash bras and socks in a lingerie bag to avoid tangling – Drain hand washables and press the water out instead of wringing – Sit when ironing – Adjust the ironing board height – Slide the iron onto an asbestos pad between items to avoid lifting – Use a lightweight iron – Hang clothes on the doorknob instead of the top of the door Taking Care of the Kids – Plan activities around the table or in the living room to allow sitting – Instead of going to the zoo, go to the park where you can sit or lie down – Delegate some of the childcare responsibilities if possible – Teach smaller children to climb on lap instead of being lifted – Teach children to make a game out of some of the household chores Working – Plan workload around your best time of day – Arrange workspace ergonomically – Take periodic rest breaks Getting Out – – – – – Wear comfortable clothing Use adaptive equipment Select less strenuous activities Go out with a friend Use a wheelchair or golf cart 36

Suggestions for Energy Conservation: Activities of Daily Living Preparing Meals – Assemble all ingredients before you start – Use cookware you can serve from – Use smaller appliances (mixers, toaster, microwave) – Use electric knife and can opener – Buy ergonomically designed utensils – Transport items on a rolling cart – Store frequently used items at chest level to avoid bending and stretching – Line ovens and burner drip pans with aluminum foil – Sit while preparing food – Rest elbows on table or counter – Let dishes soak rather than scrubbing – Let dishes air dry – Use a dishwasher if possible – Delegate dishwashing – Use a jar opener – Use a rubber mat or towel under mixing bowls to help steady them when mixing – Don't lift heavy pans off the stove – Ladle the food out at the stove – Use mitten pot-holders to take advantage of the entire hand to lift – Use place mats instead of tablecloths - they are more hygienic and easy to clean – Use lightweight utensils – Prepare double portions and freeze half for later – Drag garbage bags instead of lifting 37

Suggestions for Energy Conservation: Activities of Daily Living Walking/Moving – Wear low-heeled shoes – Wear shoes with a shock-absorbent sole or insole – Use a wheelchair for long trips (the mall for example) – Maintain good posture when retrieving – Use cruise control if possible – Install hand rails and ramps – Place chairs strategically to allow stops – Disconnect automatic door closing mechanisms Housekeeping – Spread tasks out over the week – Do a little bit each day – Delegate heavy work – Hire help – Use a wheeled cart or carpenter's apron to carry supplies – Do whatever you can sitting – Use long-handled duster, mop etc. – Use a long-handled dust pan Shopping – Make a list first – Have someone help put groceries in the car – Use a power scooter if the store has one – Request store assistance with shopping and getting to the car – Shop at less busy times – Shop with a friend – Delegate shopping – Shop online! Note: "Suggestions for Energy Conservation" was written by Eileen Donovan, PT, Med. A physical therapist at the University of Texas M.D. Anderson Cancer Center. The publisher and author grant permission to photocopy these "Suggestions for Energy Conservation" so that they can be shared with patients. 38

Make This Plan a Permanent Part of Your Life The attention you give to following your treatment plan will pay off for you! You can improve your ability to be active and your quality of life by following this treatment plan. We know that following a treatment plan can be difficult. If you are having trouble sticking to your treatment plan, please do not change anything. Talk with your nurse or primary healthcare provider for help! The Hurdles People Often Experience Are: Cost of medicines Side-effects of medicines Lack of time to exercise Complexity of treatment Difficulty following recommended diet We can help and we want to help. Talk with your nurse or primary healthcare provider about these barriers and we can work out solutions together! We are here for you! 39

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