Caregiver Contribution CC-SCHFI- English

CC-SCHFI (English)

Adapted By

Ercole Vellone, PhD, RN, FESC

Associate Professor in Nursing Science

Department of Biomedicine and Prevention University of Rome “Tor Vergata”, Via Montpellier, 1 – 00133 Rome, Italy Phone + 39 06 72596802 Fax + 39 0672596961 Mobile + 393387491811 Skype: ercole.vellone email: ercole.vellone@uniroma2.it

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CAREGIVER CONTRIBUTION TO SELF-CARE OF HEART FAILURE INDEX

All answers are confidential.

We kindly ask you to think about the care you have given to the person with Heart Failure in the past month. There are no right or wrong answers.

How often do you recommend to the person you care for the following things?

(Or, how often do you do these activities because the person you care for is not able to do them).

SECTION A:

	Never or rarely	Sometimes	Frequently	Always or daily
1. To check the weight ?	1	2	3	4
2. To check the ankles for swelling?	1	2	3	4
3. To try to avoid getting sick (e.g., flu shot, avoid ill people)?	1	2	3	4
4. To do some physical activity?	1	2	3	4
5. To keep doctor or nurse appointments?	1	2	3	4
6. To eat a low salt diet?	1	2	3	4
7. To exercise for 30 minutes?	1	2	3	4
8. To not forget to take medicines?	1	2	3	4
9. To ask for low salt items when eating out or visiting others?	1	2	3	4
10. To 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, did the person you care for have trouble breathing or ankle swelling? Circle one.

0) No

1) Yes

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

(circle one number)

	Has 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

If the person you care for has trouble breathing or ankle swelling, how likely are you to recommend (or do) one of these remedies?

(circle one number for each remedy)

	Not Likely	Somewhat Likely	Likely	Very Likely
12. To reduce the salt in the diet	1	2	3	4
13. To reduce fluid intake	1	2	3	4
14. To take an extra water pill	1	2	3	4
15. To call the doctor or nurse for guidance	1	2	3	4

16. Think of a remedy you tried the last time the person you care for 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 reference to the person you care for, in general, how confident are you that you can:

	Not Confident	Somewhat Confident	Very Confident	Extremely Confident
17. Keep him/her free of heart failure symptoms?	1	2	3	4
18. Follow the given treatment advice?	1	2	3	4
19. Evaluate the importance of symptoms?	1	2	3	4
20. Recognize changes in him/her health when they occur?	1	2	3	4
21. Do something that will relieve him/her symptoms?	1	2	3	4
22. Evaluate how well a remedy works?	1	2	3	4