Sally Beattie, RN, MS, ACNS, GNP-BC

 The publications in Advanstar Communications' Life Sciences Group and its Web portal, 

 are collaborating in a coordinated, interdisciplinary initiative to address this major public health issue: cardiometabolic disorders and weight. To read the joint introductory articles in this series, visit the following links:



Cardiometabolic Disorders and Weight: Action for Outcomes

A complex constellation of interrelated conditions

 and works full time as a cashier at a local grocery store. She receives health benefits. A year ago, she completed treatment for stage 3 breast cancer, having undergone chemotherapy, a right mastectomy, and radiation. She has been feeling well and enjoying life despite having to wear a Job’s sleeve for lymphedema on her right arm. Just prior to her cancer diagnosis, Fran had been diagnosed with essential hypertension (HTN).

 Identifiable risk factors were her age, family history of HTN in her deceased father, and a reportedly high intake of sodium.

 A review of her medical records indicates a thiazide diuretic had been prescribed along with lifestyle modifications to facilitate meeting the treatment goals.1 You also note a work-up had not revealed any hypertensive cardiovascular disease (CVD), or neurological, retinal, or kidney end organ damage.



Fran arrives today for a routine follow-up visit with her new primary care physician. You note that on her last three visits with the oncologist, her systolic blood pressure (BP) was between 146 mm Hg and 154 mm Hg. Her diastolic BP was within normal limits (WNL). You ask Fran if she’s been taking the diuretic for her hypertension and she replies, “When all the cancer treatment was going on I never even thought about my blood pressure, and since I’ve been feeling so well and no one’s mentioned it, I figured it wasn’t a problem anymore.” Further discussion reveals that Fran continues to eat a diet rather high in sodium and calories, but she is walking 30 minutes three days per week, weather permitting, a behavior she initiated after her cancer treatment was over. She denies any shortness of breath with this or other moderately exertional activities. She also drinks a glass or two of wine each evening to celebrate life. She reports a good relationship with her daughter and husband, especially after the cancer. When asked if Fran understands the risks of untreated HTN, she replies, “Sort of, but it can’t be as dangerous as having cancer.”

Your physical findings upon arriving in the exam room reveal the following: a body mass index (BMI) of 25.0 and an apical heart rate of 82 beats per minute and regular. After Fran has been seated for five minutes in a chair, feet on the floor and arms supported at heart level, her BP measures 152/82 mm Hg on the right.

 Today’s blood lab results reveal that her glucose, hematocrit, potassium, creatinine, calcium, and urine studies were all WNL and a fasting lipid profile was pending.

 Her clinician conducts an examination including auscultation for carotid, abdominal, and femoral bruits; palpation of the thyroid gland; listens to her heart and lungs; palpates her abdomen for the presence of masses and aortic pulsation; examines the lower extremities for edema; and concludes with a neurological assessment.1,2 He performs an electrocardiogram, which is normal, and inspects her retinas, which do not reveal changes consistent with HTN. He rewrites a prescription for the diuretic and tells Fran that if this and prescribed lifestyle modifications do not bring her BP to goal, he would likely have to add a second medication.1,5 Before she leaves, the clinician asks you to meet with Fran to make sure she understands the treatment plan and goals of therapy.




• Deficient knowledge related to diagnosis and disease management.
• Risk for imbalanced nutrition: more than body requirements related to excess calorie and sodium intake.
• Risk for ineffective therapeutic regimen related to multifactorial treatment plan; lymphedema; lifestyle habits contributing to HTN.
• Risk for noncompliance related to lack of physical symptoms and failure to perceive seriousness or chronic nature of HTN.



• Verbalize her risk factors for and complications associated with uncontrolled HTN.
• Verbalize treatment goals and how these are met.
• Initiate recommended lifestyle modifications:
• Achieve/maintain weight loss so measured BMI remains less than 25.
• Adopt an eating plan based on the Dietary Approach to Stop Hypertension (DASH), reducing saturated fat and cholesterol to less than 30% of dietary intake.
• Reduce dietary sodium intake to no more than 2,400 mg of sodium per day.
• Engage in regular/brisk exercise of 30 to 45 minutes three to seven days per week.
• Limit alcohol to one drink per day; 12 oz beer or 5 oz wine.
• Ensure diet includes daily allowance of calcium, potassium, and magnesium.
• Demonstrate ability to measure BP at home.
• Explain action, dosage, and side effects of prescribed medication(s); take as directed.
• Identify contraindicated over-the-counter medications-those high in sodium, those known to elevate BP.
• Develop strategy for home BP measurement.
• Verbalize consequences of noncompliance with prescribed treatment regimen.
• Identify sources of support for assisting with compliance.
• Keep scheduled follow-up appointments.




• Using terminology Fran understands, review and discuss BP concepts; treatment goals and how these are met; discuss effects uncontrolled HTN has on cardiovascular system, brain, kidneys, and eyes; facilitate information with written and visual take-home aides.
• Explain concept of “control vs. cure” as HTN is a chronic disease state; reinforce efficacy of treatment plan if adhered to, and consequences of ignoring this silent danger.
• Provide reassurance and confidence in Fran’s ability to meet treatment goals, emphasizing her ability to have control over long-term outcomes especially in light of her recent show of strength undergoing treatment for breast cancer.
• Teach spouse how to measure Fran’s BP at home and instruct them to keep a log.
• Discuss lifestyle modifications that can reduce HTN and, in some cases, minimize the need for multiple medications.
• Refer to registered dietician to facilitate formulation of acceptable dietary plan in accordance with the Joint National Committee Seventh Report recommendations, as well as for weight loss and maintenance.
• Recommend Fran increase walking to a minimum of 30 to 45 minutes five to seven days a week; explore options for maintaining structured activity during inclement weather.
• Provide guidelines for prescribed medication including dosage, action, side effects, and precautions.
• Provide list of contraindicated over-the-counter medications (

http://www.webmd.com/hypertension-high-blood-pressure/guide/medications-cause

) and advise Fran to check with clinician before taking any new medication.
• Explain importance of and need for regular follow-up appointments to monitor response to treatment and make changes as needed
• Include spouse in all discussions.




Fran, along with her husband, returns to the clinic in approximately one month. Her average BP has been 140/86 mm Hg, and today it is 142/86 mm Hg. She has lost a pound, and has followed your recommendation that she walk a little longer and more frequently. She and her husband also have checked out the walking program at the local indoor mall, something that had been put on hold when she was diagnosed with cancer. After visiting with the dietician, Fran has managed to reduce some of the salt in her diet and increase her intake of fruits and vegetables. She’s obtained some low-sodium recipes and is excited about learning to cook with other spices. She admits that this is the most difficult challenge as she loves salt, but she adds that having had cancer was scary enough and she doesn’t want to “now get sick from high blood pressure when I don’t need to.” She’s taking her medication and overall feeling well, “but I never felt sick with the high blood pressure anyway.” You praise Fran for making these important lifestyle changes and explore with her where she might tweak more salt out of her diet. You reiterate you’d like to see her attain the BP goal of less than 140/90 mm Hg by next visit in a month or so. Both Fran and her husband leave thanking you for your kindness and expertise along with a promise that next time, Fran’s BP will be at goal. 


1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. 

. 2003;289(19):2560–2572.

2. Domino FJ, Kaplan NM. UpToDate Web site. Overview of hypertension in adults. 

http://www.uptodate.com/patients/content/topic.do?topicKey=~an7a7QILOHLo3/a

. Updated 2009. Accessed August 27, 2009.

3. Ignatavicius DD, Workman ML. Care of patients with vascular problems. 

: Patient-Centered Collaborative Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010.

4. World Health Organization. Obesity and overweight. Fact sheet No. 311. 

http://www.who.int/mediacentre/factsheets/fs311/en/

. September 2006. Accessed August 27, 2009.

5. Kaplan NM, Rose BD. UpToDate Web site. Choice of therapy in essential hypertension: Recommendations. 

http://www.uptodate.com/patients/content/topic.do?topicKey=~MMUHEpy46yILPM

. Updated 2009. Accessed August 27, 2009.

6. Doenges ME, Moorhouse MF, Murr AC. 

Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions

, and Rationales. 11th ed. Philadelphia, PA: FA Davis Company; 2008.

7. Carpenito-Moyet LJ. 

. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.



 
The etiology for developing essential hypertension (HTN) is still poorly understood, but there are several identified risk factors associated with its onset.


• Age - less than 60 years
• Family history - HTN in one or both parents is independently associated with developing HTN in adult life
• Race - HTN tends to be more common and more severe in the black population.

Identified modifiable risk factors include the following and their presence in association with essential HTN may affect an individual’s prognosis:
• Cigarette smoking
• Obesity (body mass index greater than or equal to 30 kg/m

)
• Physical inactivity
• Dyslipidemia
• Diabetes
• Excessive alcohol intake
• High sodium intake (average intake less than 2,300 mg of sodium per day)

The risks of ignoring the need for HTN treatment and addressing any modifiable risk factors are somewhat staggering in consideration of the following:
• Complying with HTN treatment and addressing modifiable risk factors may prevent many chronic diseases.


• HTN is the most common risk factor, leading smoking, dyslipidemia, and diabetes for premature cardiovascular disease.
• HTN commonly leads to left ventricular hypertrophy and heart failure. HTN is the most important and common risk factor for stroke.
• HTN is an identified cause of end-stage renal disease.
• Acute and marked elevations in blood pressure can result in death.



 
1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. 

. 2003;289(19):2560–2572.

2. Ignatavicius DD, Workman ML. Care of patients with vascular problems. Medical-Surgical Nursing: 

. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010.

3. Kaplan NM, Rose BD. Choice of therapy in essential hypertension: Recommendations. 

. Updated 2009. Accessed August 27, 2009.

4. Domino FJ, Kaplan NM. UpToDate Web site. Overview of hypertension in adults. 

. Updated 2009. Accessed August 27, 2009.



 
The ultimate goal of hypertension (HTN) treatment is to reduce cardiovascular (CV) and renal morbidity and mortality. Clinical trials have demonstrated that appropriate anti-HTN therapy is associated with significant reductions in the incidence of major CV events, i.e., stroke, heart failure, and myocardial infarction.



To gain these benefits, the following therapeutic goals have been established:
• Systolic blood pressure (SBP) less than 140 mm Hg
• Diastolic blood pressure (DBP) less than 90 mm Hg (but no less then 65 mm Hg in elderly patients)
• In hypertensive patients with diabetes or renal disease, the goal is less than 130/80 mm Hg.

These BP goals are met by a combination of nonpharmacologic lifestyle modifications and drug therapy, a complete summary of which can be found at 

http://www.nhlbi.nih.gov/guidelines/hypertension

http://www.uptodate.com/online/content/topic.do?topicKey=hyperten/23203&review



Nonpharmacologic therapy includes restricting dietary sodium, reducing weight if needed, avoiding excess alcohol, and performing regular aerobic exercise. In mildly hypertensive individuals, nonpharmacologic therapy alone may bring the BP to goal and should be prescribed for all individuals with HTN.



However, most will, in addition, require at least one or a combination of drugs to meet their treatment goal. The three main classes of drugs used for initial treatment are the thiazide diuretics, long-acting calcium channel blockers, and angiotensin modifiers such as converting enzyme (ACE) inhibitors or angiotensin II receptor blockers. Each of these agents offers roughly the same degree of effectiveness in lowering the BP, producing an acceptable antihypertensive response in 30% to 50% of patients. Initiating a combination of two drugs is appropriate when the BP is greater than or equal to 20/10 mm Hg above goal.

Once therapy is initiated, it is recommended that most patients return for follow-up and adjustments if needed every four to six weeks until the BP goal is met. Once BP is at goal and stable, follow-up visits can occur at three- to six-month intervals, pending presence of comorbidities and other health needs.



. Updated 2009. Accessed August 27, 2009.

3. Kaplan NM, Rose BD. UpToDate Web site. Choice of therapy in essential hypertension: Recommendations. 

. Updated 2009. Accessed August 27, 2009.

The most common reason surveyed for outpatient office visits for adults in the United States is the treatment of essential hypertension (HTN)-HTN unrelated to another underlying condition, such as pheochromocytoma, primary aldosteronism, or renovascular disease. The number of patients with HTN continues to grow as the population ages, occurring in more than half of persons over 65 years of age.

The Seventh Report of the Joint National Committee (JNC 7) defines normal blood pressure (BP) as systolic less than 120 mm Hg and diastolic less than 80 mm Hg.

 Beyond that, the following classification for HTN has been established and is based on the average of two or more properly measured readings on each of two or more office visits.



Prehypertension:
Systolic 120 mm Hg to 139 mm Hg or diastolic 80 mm Hg to 90 mm Hg (those in this category are at increased risk for developing HTN)

Hypertension:
Stage 1 HTN: Systolic 140 mm Hg to 159 mm Hg or diastolic 90 mm Hg to 99 mm Hg

Stage 2 HTN: Systolic greater than or equal to 160 mm Hg or diastolic greater than or equal to 100 mm Hg

The higher value of either the systolic or diastolic component determines the severity of HTN. In persons less than 65 years of age, the systolic BP is a greater predictor of risk for a heart attack, heart failure, stroke, and kidney disease. This risk is continuous, consistent, and increases for each increment in systolic BP than for an equivalent increase in diastolic BP, independently of other risk factors. Each incremental rise in systolic BP of 20 mm Hg, or 10 mm Hg in diastolic BP, doubles the risk for coronary artery disease (CVD) from a range of 115/75 mm Hg to 185/115 mm Hg. On the other hand, in persons over 65 years of age, an increased pulse pressure is the defining criterion associated with an adverse event.

 is a clinical manager at the University of Missouri Hospital and Clinics, Columbia, MO. She is also a member of the 

Articles

Patients may be overwhelmed with the multiple lifestyle changes that control of hypertension requires. RN's care guide will help them understand why each step toward normal blood pressure is so important for long-term health.

Hypertension: Nursing guide to this cardiac pressure cooker

, are collaborating in a coordinated, interdisciplinary initiative to address this major public health issue-cardiometabolic disorders and weight. To read the joint introductory articles in this series, visit the following links:

									http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=621950

									http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=621955

is a booking agent for a local jazz club in a university town in the Midwest. He recently attended a local health fair and was found to have a fasting plasma glucose (FPG) level of 200 mg/dL. Upon questioning by the nurse, Jon said he didn't smoke; his blood pressure (BP), just measured, was 128/78 mm Hg; and he was unaware of his cholesterol level. The nurse noted he appeared to be overweight and asked if he had experienced any classic symptoms of diabetes, such as polyuria, polydipsia, polyphagia, or unexplained weight loss.

  He denied noticing any of these, but did comment that his older sister had type 2 diabetes. The nurse reinforced the need for Jon to find out if he also had type 2 diabetes, recognizing he had several risk factors. She explained that people with this disease may remain asymptomatic for years, but during that time, complications can begin to develop.

  He was advised to see his "regular" healthcare provider so a repeat FPG could be performed, one of the definitive criteria for the diagnosis of type 2 diabetes.

A week later, Jon followed through with the nurse's recommendation. His FPG on this occasion was 147 mg/dL. His hemoglobin A

-a measurement of blood glucose control for the previous three months-was elevated, at 8.7%.

  A fasting lipid profile (FLP) revealed the following: total cholesterol 198 mg/dL; low-density lipoprotein (LDL) 110 mg/dL; high-density lipoprotein (HDL) 36 mg/dL; and triglycerides 146 mg/dL. Serum chemistries, including liver function tests and creatinine, were all within normal limits, as was his albuminuria, and a calculated glomerular filtration rate was pending.

  His BP was 128/76 mm Hg, resting heart rate was 86 bpm, and he had a normal resting EKG. He denied any symptoms of overt cardiovascular disease (CVD), but said, "I think my sister takes medicine for heart pain." Other than that, he was unaware of any family history of CVD. His calculated body mass index (BMI) was 28, indicating he was overweight at 189 pounds on his 5'9" frame.

He did not have any signs or symptoms of peripheral neuropathy and used reading glasses. He denied having any known allergies or ever having received a flu or pneumococcal vaccine. 

Based on his two FPG readings and associated risk factors, he was diagnosed with having type 2 diabetes. Per current recommended guidelines, he was prescribed the following medications: metformin, a statin, and aspirin.

As the senior registered nurse in the office, you are asked to meet with Jon to explain and arrange for the further components of his initial evaluation, and to assist in formulating an individualized plan to help him manage his diabetes. Before you can do this, however, you need to gather some more information about his background and lifestyle.

You learn he dropped out of college after five semesters and does not work a "9-to-5" job; rather, he is "on the go" during most of his waking hours. He gets little exercise except for that attained during his regular daily activities-going up and down stairs, walking to his car, carrying out activities of daily living, etc. He doesn't smoke, but admits to drinking four to five beers per day, and three cups of coffee in the morning. He lives alone and eats most meals out and at irregular hours. He consumes primarily a Western diet, characterized by a high intake of red and/or processed meat, high-fat dairy products, and lots of sweets and desserts.

  He has a wide circle of friends and describes himself as "very social"; he's been divorced for 10 years and does not have children. He denies any history of depression or sexual dysfunction. He says that when he feels stressed, meeting with his buddies and "drinking some beers" usually helps, and that he sleeps about five to six hours per night. He admits he's never been good at taking pills and has not been successful in the past in maintaining a healthy level of physical activity due to his hectic schedule, but acknowledges he needs to lose weight. He has a high-deductable health insurance plan with limited copay and medication coverage, and admits to feeling a tad overwhelmed with his diagnosis, as he's aware of some of its associated complications. He says he doesn't know much else about type 2 diabetes and that he's never really been sick. 

Following the initial diagnosis and discussion with you, Jon did meet with a dietitian twice to begin education related to MNT, and he has another appointment with her in a few weeks. An ophthalmologist performed an initial dilated and comprehensive eye examination, which revealed the absence of retinopathy; an appointment with his dentist was scheduled for a future date. He had called once after his initial meeting to ask some questions regarding use of his glucometer and commented that he was "trying" to make the recommended lifestyle changes, especially in the area of adjusting his caloric intake. 

He kept his three-month follow-up appointment with his primary healthcare provider, and you met with him again at that time. He was able to define type 2 diabetes, identify his risk factors, and explain in his own words why he was taking each medication. His BP was 128/78 mm Hg; A

 was measured at 7.5%; HDL 38 mg/dL; LDL 98 mg/dL; and he had lost 1.5 pounds. He said he was walking once a day for 10 minutes, sometimes longer; but hadn't yet "fit in" walking two times a day, nor had he incorporated any resistance-type exercise into his "routine." He had not reviewed the DVDs you had provided. He had cut back on his alcohol intake, but not to the recommended two drinks per day. Although he was able to describe why it was important, he said he didn't "get around" to checking his BG every day, but he had kept a record and was checking it at least once every other day. He was taking his medications as prescribed, and thus far he was able to afford them, but said as his income is dependent on getting the gig, he did have some anxiety about maintaining this expense. Jon said he had spoken several times with his sister about their shared diagnosis and that she was a valuable and useful source of information and support. 

You praise and reinforce the positive changes Jon has made, and explain that his weight, lipids, and A

 are moving in the right direction, repeating again the goals for each of these parameters. You discuss strategies for increasing his activity and limiting his alcohol intake and explore potential barriers to meeting the predetermined goals. Throughout the meeting, you provide support by acknowledging that learning to live with diabetes and making multiple lifestyle changes is indeed challenging. You encourage him to continue to make appropriate choices regarding his health, repeating the vital need to stave away serious complications. You refer him to the office practice social worker in order to explore available resources to help pay for medications, and to subsidize participation in a medically monitored, structured exercise program. You explain that he needs to continue taking his current medications and that at his next three-month appointment, pending his A

, a decision will be made regarding the need to add a second oral agent to help achieve and sustain BG goals. In the meantime, he can call anytime to ask questions or express concerns about his health. 

Learning to live with diabetes requires patience and commitment from both the patient and the healthcare team to ensure that the disease management principles are met and sustained throughout life. 

Morbidity involves both macro-and microvascular disease, so interventions to limit end organ damage are the focus of care for these patients. The major priority for diabetic patients, especially those with type 2, is prevention of CVD, which can be significantly reduced with aggressive control of the important risk factors-abstinence from smoking and management of hypertension and lipids. Glycemic control (A

 less than 7%) has been shown to significantly minimize risks for nephropathy, neuropathy, and retinopathy. Weight control, appropriate food choices, and participation in the recommended amount of exercise and physical activity will have a positive impact on minimizing the occurrence of the aforementioned complications, as well as improving overall insulin utilization. 

Follow the treatment and education of a newly diagnosed type 2 diabetes patient: taking a case history, making a diagnosis, and teaching the patient how to monitor and control blood sugar.

Diabetes: The tipping point to a metabolic meltdown

 who works as a purchasing agent for a medical equipment company. She has three grown children and has been without major health problems or chronic illness, although for the last 35 years she has smoked half a pack of cigarettes per day. She has no allergies. She underwent a knee replacement following an accident while golfing seven years ago. Twenty years ago, her father passed away suddenly at age 68 following a ruptured aortic aneurysm; her mother, age 86, survives and is doing well despite having had two minor strokes. Last week, her only sibling, a younger brother, told her he'd had a fasting lipid profile (FLP) at an office screening health fair. He said, "It looks like my cholesterol may be too high, so they told me to get it checked again by my doctor." Sara commented that she hadn't had hers checked in several years because she had not been to that kind of a doctor. After talking with her brother, she made an appointment at a family health clinic for an FLP and was instructed to fast for at least 12 hours before having her blood drawn.

Her results revealed the following abnormalities: total cholesterol (TC) 240 mg/dL; high-density lipoprotein (HDL) 38 mg/dL; low-density lipoprotein (LDL) 164 mg/dL; and normal triglycerides (150 mg/dL).

  A fasting blood glucose was normal. The following week, a nurse practitioner saw her for a physical exam and follow-up. Her sitting blood pressure was 138/80 mm Hg; resting heart rate 86 bpm; respirations non-labored at 16 per minute; and a review of systems and the rest of the physical exam unremarkable. Sara's body mass index (BMI) was 26.8 kg/m

  Blood counts and chemistries, thyroid, and liver function studies were all normal.

The nurse practitioner went over these results with Sara. She explained the changes that occur in blood vessels as a result of uncontrolled hyperlipidemia, especially as this process relates to the development of coronary heart disease (CHD), which could lead to a heart attack. The same process, she went on to say, could occur in the carotid arteries-major arteries that feed the brain-and cause a stroke. Sara learned that an abnormal lipid profile such as hers, especially the high LDL, was of concern because it is a major risk factor for developing CHD. Other risk factors, such as her low HDL, smoking history, and age also contributed to Sara's risk for CHD, which was further influenced by her rather sedentary lifestyle and atherogenic diet.

The nurse practitioner used all this data to calculate Sara's 10-year risk for developing CHD, the results of which would facilitate decisions regarding Sara's optimum treatment regimen.

  The results indicated Sara was in the 'moderately high-risk' category.

  Based on current guidelines, she was prescribed a statin-the most powerful class of drugs for lowering LDL hyperlipidemia-and therapeutic lifestyle changes (TLC).

  As the nurse educator at the clinic, you have been asked to see Sara to assist in formulating a plan to meet the treatment goals. 

After reviewing her chart, you meet with Sara to gather some more information. You learn she has a high school education and says she understands the importance of getting her "cholesterol numbers under control" as well as the need to quit smoking so she doesn't "drop dead of a heart attack or a stroke." Two years ago, she quit smoking for six months, so she said, "I know I can do it." She also admits to the need for-and in fact looks forward to-eating better and incorporating more activity into her lifestyle. She wants to learn how to take better care of herself, but does express anxiety about whether she'll be able to make all the changes. One of her best friends quit smoking two years ago. In addition, she does belong to an HMO via her work health insurance policy.

Use our sample patient with high blood lipids as a guide for diagnosing hyperlipidemia, interpreting blood tests, and educating your own patients.

Sally Beattie, RN, MS, ACNS, GNP-BC

Articles

Hypertension: Nursing guide to this cardiac pressure cooker

Diabetes: The tipping point to a metabolic meltdown

Lipids: A nursing action plan for improving patients' lipoprotein levels