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INAPRIMA‘R’Y CARE LIPID PROGRAM _ -

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THE ROLE OF THE ADVANCED PRACTICE NURSE
IN A PRIMARY CARE LIPID PROGRAM
By

Mary Ellen Yealin

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fiilfillment of the requirements
for the degree of

MASTER OF SCENCE IN NURSING

College of Nursing

1997

ABSTRACT

THE ROLE OF THE ADVANCED PRACTICE NURSE
IN A PRIMARY CARE LIPID PROGRAM

By

Mary Ellen Yealin

Heart disease has been identified as the United States number one health problem.
Research consistently shows that some of the risks that increase the incidence of heart
disease are modifiable, and that management of these risks is the key to coronary artery
disease prevention. Dyslipidemia has been identified as a strong but modifiable risk factor
in the development of heart disease and this risk is compounded in the presence of other
identified n'sks factors. The National Cholesterol Education Program was published in
1988, and updated in 1993, to give guidelines for the treatment of various dyslipidemias.
This paper will utilize these guidelines as the foundation for the development of the
advanced practice nurse role in a lipid modification program within a primary family
practice. The Theory of Goal Attainment developed by Imogene King will serve as the
conceptual framework for this program. The Transtheoretical Model of Stage-Based

Change will also be used as a basis for nursing interventions.

ACKNOWLEDGMENTS

This paper would never have been written without the support and input of several
people. I knew on the first day of class when they discussed a "scholarly project" it would
be one of the biggest challenges of my life. Now that it is finally done, I realize that I was
right.

My committee was outstanding. I found my chairperson, Kate Lein, purely by
accident and will never forget her enthusiasm, her support and sense of humor. I truly
hope to emulate her love for her job in my own career. Kathy Dontje was extremely
helpfiil in pointing out the needed details and structure of my project. Her advice
provided a major turning point in the development of this paper, and I admire her
understanding of the advanced practice role. Gabriele Kende provided me with a new
respect for the English language, I will forever be humbled and amazed at her grasp of
language in general. I will also never discuss triglycerides again without thinking of her.

I must thank my friend Renee Page], who provided support to me as she also
struggled with her project. Her phone calls, advice and stories about her own process
provided me with hope, hysteria and laughter. Thank you to Renee Canady, who
provided guidance throughout the entire process, I am truly grateful. Thank you also to
my typist, Lisa Morgansai, who has bailed me out numerous times throughout this

program. I would never have made it without everyone's help.

iv

TABLE OF CONTENTS

LIST OF TABLES ......................................................................................... vi
LIST OF FIGURES ....................................................................................... vii
INTRODUCTION .............................................. « ............................................. 1
CHAPTER 1
CONCEPTUAL FRAMEWORK .................................................................... 5
Goal Attainment Theory ............................................................ - ................ 5
Change Theory .......................................................................................... 9
CHAPTER 2
LITERATURE REVIEW .............................................................................. 15
CHAPTER 3
PROJECT DEVELOPMENT ........................................................................ 22
Clinic Personnel ............................................................................................. 25
Clinic Process ................................................................................................ 28
Patient Criteria .............................................................................................. 35
Rationale ....................................................................................................... 36
Evaluation ..................................................................................................... 37
Pilot Materials ............................................................................................... 38
CHAPTER 4
IMPLICATIONS FOR PRACTICE .............................................................. 39

LIST OF TABLES

Table 1 - Treatment Decisions Based on LDL Cholesterol ........................................ 23
Table 2 - Risk Factors for Heart Disease Other than LDL Cholesterol ....................... 24
Table 3 - NCEP Guidelines ....................................................................................... 27

vi

LIST OF FIGURES

Figure 1 - A Process of Human Interactions ......................................................... 8

Figure 2 - Stages of Health Behavior Change ...................................................... 12
Figure 3 - Evaluation of Client's Stage of Change ................................................ 13
Figure 4 - Assisting Health Behavior Change ....................................................... 14
Figure 5 - Primary Prevention in Adults without CHD ......................................... 31
Figure 6 - Secondary Prevention in Adults with CHD .......................................... 32
Figure 7 - Primary Prevention Algorithm ............................................................. 33
Figure 8 - Secondary Prevention Algorithm ......................................................... 34

vii

INTRODUCTION

Heart disease has been identified as our nation's number one health problem
(NCEP, 1993; Brown, 1996). Deaths due to cardiac disease are estimated to be at least
500,000 persons annually (NCEP, I993; Ziajka, 1995). Millions are disabled each year
due to cardiac problems, such as myocardial infarction, congestive heart failure and
angina. Costs associated with heart disease exceed $100 billion annually, due to lost wages
and medical treatment (NCEP, 1993). Multiple studies have identified risk factors that
may increase likelihood of cardiac related illness. While some risks outweigh others,
multiple risks increase the possibility of developing heart disease in a linear pattern
(NCEP, 1993). Risk factors that have been identified include those that are not amenable
to change, and those that can, at least partially, be controlled. Lifestyle changes and/or the
institution of medical therapy have been shown to be extremely effective in decreasing a
person's risk for heart disease.

Nonmodifiable risk factors include age, sex, ethnicity and family history of heart
disease. Modifiable risk factors include cigarette smoking, hypertension, diabetes mellitus,
and dyslipidemias. Obesity and a sedentary lifestyle are frequently included as risk factors,
but have not been directly linked to the development of heart disease. However, people
with these characteristics frequently have hypertension, dyslipidemias, and possibly
glucose intolerance if not diabetes, and therefore are more likely to be found in the high
risk population (NCEP, 1993).

Dyslipidemia has long been identified as a risk factor associated with the

development of heart disease. Primary dyslipidemia is a condition that may include

elevated low density lipoproteins (LDL) or triglycerides, or too low levels of high density
lipoproteins (HDL) due to genetic influence and current risk factors. Secondary causes of
dyslipidemias include hypothyroidism, diabetes, and some medications. Management of

secondary factors is often sufficient treatment to correct abnormalities.

LIPID INTERVENTION

Lipid abnormalities have clearly been associated with increased risk for
cardiovascular disease. Numerous studies have shown that interventions which decrease
LDL cholesterol are very effective in preventing cardiac disease and sudden death due to
cardiac disease (Braunwald, 1997; NCEP, 1993). Aggressive treatment for those persons
with established coronary artery disease has also been shown to dramatically reduce fiiture
cardiac events (Brown, 1996; Davidson, 1996). Despite this convincing evidence, studies
that monitor physician compliance have shown that lipid abnormalities are not treated
adequately, and are sometimes ignored (Levins & Omstein, 1990; Ziajka, 1995). This
lack of treatment occurs despite the fact that the National Cholesterol Education Program
(NCEP) guidelines were established and made widely available.

The National Cholesterol Education Program was developed by an expert panel
formed to create guidelines for the treatment of dyslipidemias, as well as other risk factors
that contribute to the development of heart disease. The group published their first report
of recommendations in 1988, and later updated and revised some of the recommendations
in 1993. The second report is still utilized and widely available for both health
professionals and the general public.

Lipid programs are ofien associated with a larger clinic, specialty office or
university program. Referrals may come from within a large practice, and other clinics get
their referrals from the community. One established lipid program director estimated that
a primary care office with eight or more providers could support a full time lipid clinic

based on internal referrals alone (Ziajka, 1995). A well-managed lipid program is often a

profitable undertaking if coding, adherence to insurance guidelines and efficiency are
maintained closely (Brown, 1996; Ziajka, 1995).

Clinics dealing specifically with lipid abnormalities have been quite successful in
improving cholesterol levels, and thereby lowering CAD risk, through patient education,
lifestyle changes (dietary, exercise), and in some cases, medications (Brown, 1996; Ziajka,
I995). Established lipid clinics specifically state that the majority of education, treatment,
and monitoring of patients within the clinic can be efficiently and cost effectively managed
by nurses at various levels (Brown, 1996; Ziajka, I995; NCEP, 1993). The advanced

practice nurse role within the lipid modification clinic will be the focus of this paper.

STATEMENT OF PROBLEM

To this date, there is not a lipid program that deals with a primary care population
in Kalamazoo, Michigan. The two existing programs are within "cardiac rehabilitation"
programs where clients have already been diagnosed with heart disease. Currently
Kalamazoo has at least 25 cardiologists who work in two local hospitals and several small
affiliated hospitals in neighboring towns.

The identified location for the lipid program is a large family practice that has 22
physicians, three physician assistants and one family nurse practitioner. All providers
work at offices in Portage, Kalamazoo, Richland and Three Rivers, Michigan. Current
active patients (defined as those patients who have had at least one interaction with the
clinic in the last three years) are estimated at 60.000. An average of 250 new patients
register each month between the four sites. Current estimates of reimbursement type
include: private pay insurance, 35%; HMO’s, 34%; Medicare,10‘.’/o; Medicaid, <l°/o; self-
pay, 17% and other, 3%. -

General verbal report among providers and preliminary chart audits indicate that
lipid abnormalities are frequently not treated according to NCEP guidelines. Possibilities

for lack of treatment have been proposed in the literature and include lack of time, lack of

knowledge, and need for frequent follow-up (Ziajka, 1995). A primary care program that
monitors cholesterol levels, treatment and response to therapy in a timely manner would
greatly benefit our dyslipidemic client population. NCEP guidelines will be utilized and
individualized based on the severity of dyslipidemia and coexisting risk factors. Three
providers, a full time nurse practitioner (former cardiac nurse), the practice’s sole internist,
and a dietitian affiliated with the parent hospital have volunteered to develop, implement
and participate in a lipid program within the practice.

The APN interventions will be based on King’s Goal Attainment Theory and the
Transtheoretical Model of Change. Interventions based on these theories are expected to
bring about behavioral changes that will positively influence clients’ lipid profiles and,
therefore, decrease their risk for heart disease. Interventions will also focus on other

modifiable, associated risk factors for the development of heart disease.

Chapter 1
CONCEPTUAL FRAMEWORK

Imogene King's Goal Attainment Theory will serve as a conceptual framework for
APN interventions in the lipid program. The theory is particularly appropriate because of
its heavy emphasis on goal attainment, interactions and transactions, which will be the
basis for lipid management. King's definition of health is as follows:

dynamic life experiences ofa human being, which implies

continuous adjustment to stressors in the internal and external

environment through optimum use of one‘s own resources to

achieve maximum potential for daily living (King, 1981, p. 141).
This definition is important as it points out internal stressors (physical illness) and external
stressors (multiple role demands) that are involved in one's definition of health. Provision
of resources to adjust to these stressors (education, exercise, low-fat, low-cholesterol diet,
etc.) in addition to improving physical health will be attempted.

King considers three areas in an individual‘s social system that interact
simultaneously . The first area is the "personal system" which she defines as "A unified,
complex, whole self who perceives, thinks, desires, imagines, decides, identifies goals and
selects means to achieve them " (King, I981, p. 41). A related concept of specific
importance within King's theory is perception. Perception is described as a process of
organizing, interpreting and transforming information from sense, data and memory. It is
a process of human transaction with the environment. It gives meaning to one‘s

experience, represents one‘s image of reality and influences one‘s behavior (King, 1981).

The second area that King describes in the social system is the "interpersonal
system". The interpersonal system is defined as "a system of two, three, or more
individuals interacting in a given situation" (King , 1981, p. 141). According to King’s
theory another component of the theory is interaction, a process of perception and
communication between persons and environment that may consist of goal-directed verbal
and nonverbal behaviors. Interactions are influenced by knowledge, needs, goals, past
experiences and perceptions. Communication occurs when information is given from one
person to another, directly or indirectly, and is also the vehicle for maintenance of human
relationships. Transactions are a goal-directed process of interaction in which human
beings communicate with the environment to achieve goals that are valued. Role is a
concept comprised of three elements: a set of behaviors expected when occupying a
position in a social system, rules or procedures defining rights and obligations in a position
in an organization; and a relationship with specific situations for a purpose. Stress is a
dynamic state in which a person interacts with the environment to maintain balance for
growth, development and performance which involves energy exchange and information
regulation and control of stressors (King, 1981).

The last area of King's interacting system is the "social system" or society. Several
concepts are also inherent to this theory. An "organization“ is composed of human beings
who have prescribed roles and positions; they use resources to accomplish personal and
organizational goals. Authority is described as a transactional process whereby
recognition, acceptance and compliance results from active reciprocal relations in which
members’ values, background and perception define and accept authority. Power is a
process by which one or more persons influence another in a situation. Status is a position
of an individual in a group or a group in relation to other groups in an organization.
Decision making occurs through a dynamic and systematic process by which goal directed

choices are made by an individual or group (King, 1981).

The three systems relate to each other in the following manner. Interaction leads
to transaction. Interaction occurs when individuals mutually identify goals, as well as
means to achieve them. Interactions are composed of a communication and transaction
component. When they agree to the means to implement the goals, they move towards
transactions. Transactions are the processes that are goal directed. First the informational
component of interactions can be observed as communication. Second, the valuational
component of interactions can be observed as transaction because one obviously values a
goal, identifies means to achieve it and takes action to attain it. Stress is reduced when the
action stage of transactions are made (Fawcett, 1989) (See Figure 1).

A typical representation of this with the lipid clinic may be as follows: A client has
an abnormal lipid profile and her provider has recommended enrollment in the lipid clinic.
The patient enrolls and meets with the APN, who fithher explains lipid abnormalities,
etiologies, treatments, etc. (interaction). Identification of goals to reduce lipids takes
place between the lipid provider and patient (communication/transaction). Actual changes
on behalf ofthe patient due to the transaction-- changes in diet, exercise, etc., are
considered action/transaction. At the next interaction, reevaluation of lipid goals takes
place after response has been ascertained (compliance with diet, changes in lipid levels,
routine exercise), as well as concerns of the client and provider’s are addressed
(feedback).

Because so many of the actual interventions in the lipid program involve effort by
the client, the goal attainment theory is of particular importance. The clients are expected
to be a active participants and must share in the goal-setting process. Because they must
also perceive their abnormal lipids as a health risk, interactions must take place on a
regular basis to reevaluate their understanding and actions to carry out goal attainment.
Addressing clients’ concerns and continually setting goals is imperative for program

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CHANGE THEORY

Prochaska's Transtheoretical Model of Change or "Stage-Based" approach will be
utilized as a theoretical framework in this clinic. This theory describes five stages of
readiness that people progress through when changing their health behavior. These stages
are cyclical, as clients tend to progress through stages as they move closer to their goal;
however, they may regress to any of the preceding stages at any given time (Conn, 1994;
Keller, 1997; Prochaska, 1992) (See Figure 2). Clients may enter the program at any
stage of change, and the APN will need to determine what stage the individual is in prior
to implementing a treatment plan. The planned interventions will be directly related to the
client’s current stage (See Figure 3). Interventions that have been based on incorrectly
assessed stages have been consistently shown to be ineffective in promoting behavior
change (Prochaska, 1992) (See Figure 4).

The stages in the theory begin with the "precontemplation" stage. In this stage
clients are not giving serious thought to adopting any behavior change. They cannot see
the benefit of their behavior change and do not think the benefit will outweigh the effort of
making the change. Their lack of interest may result from having inadequate information
about their health risk (Conn, 1994). Clients may be in this stage prior to entering the
lipid program and may not enroll due to this reason. Evaluation of client knowledge
regarding dyslipidemias and heart disease, as well as providing education, would be an
important intervention during this time.

In the "contemplation" stage, clients are starting to give serious thought to change.
They actively seek information that supports the merit of the desired behavior. This is the
stage where clients may state they are planning to change in the near future (Cassidy,
1997; Conn, 1994; Prochaska, 1992). Clients may have received information about
dyslipidemia, or have some knowledge or experience with lipid abnormalities or heart
disease that motivates their behavior. They are more likely to enroll in the lipid program

during this stage.

10

During the "preparation" stage clients begin to prepare for behavior change. They
accept that the benefits of behavior change will outweigh the risks of not changing. They
may begin to make small changes in their behavior and consider other changes leading to
the desired behavior (Cassidy, 1997; Champion, 1994; Conn, 1994). This stage may take
place at the first clinic intervention and include goal setting for behavior changes.

The "action" stage describes the period when clients are actively using strategies to
change their undesired behaviors to the desired behaviors. New routines are developed
that support new behavior changes (Conn, 1994). This stage would likely follow the early
interventions and dietary consultation. Frequent interventions to support new behavior
and prevent relapse are necessary (Hecht et al, 1994).

The "maintenance" stage involves the integration of behavioral changes into
everyday lifestyle. Individuals stay in this phase until they no longer feel the temptation to
regress to old behaviors (Conn, 1994). Clients who sometimes struggle with exercise
regimens, dietary changes or new medication routines, but are usually successfirl in
carrying them out, would be in this stage. Continued support during this stage is
important because relapse is common (Conn, 1994; Hecht et al, 1994).

"Relapse" refers to regression to an earlier stage and may occur at any time in the
change process. Progression through the change stages without relapse is considered very
unusual. Clients often return to the “contemplation” or “preparation” stage despite having
successfully reached the “action” or “maintenance” stage of the desired behavior change
(Conn, 1994; Prochaska et al, 1992). Because regression can occur at any time, and the
client may return to any stage, the APN needs to evaluate to which stage the client has
regressed. The individual who has frequent relapses may need more frequent interventions
such as phone calls, dietitian visits, etc., to promote advancement tot he next stage.

Because this is a voluntary, outpatient program, clients may drop out of the
program if they feel the advantages of behavior change do not outweigh the

disadvantages. Reassurance for those clients who feel “relapse” is failure will be

1]

important. Studies that utilize the Transtheoretical Model have shown that numerous
attempts to change behavior are often necessary to bring about permanent change
(Prochaska, 1992).

Because of the heavy emphasis on changing clients‘ behaviors, the Transtheoretical
Model of Change is a conceptual framework that will assist the APN to assess and
intervene in an effective manner. This theory and King’s Goal Attainment Theory will

complement each other when planning and implementing nursing interventions.

 

Precontem latlor. b Contemplation———> Prepara ion

//

elapse 4 Action

Maintenance

 

Permanent Change

Figure 2: STAGES OF HEALTH BEHAVIOR CHANGE
Adapted fi'om: Prochaska and DiClemente, 1992.

I3

STAGES OF CHANGE

 

 

Precontemplators: Initial question "Have you thought about making any changes that may
improve your cholesterol levels or health in the next 6 months? Those individuals who
respond negatively are considered to be in the "precontemplation" stage.

Contemplators: Those individuals who respond positively to the above question are asked, "Do
you intend to make any of these changes in the next 30 days? Those that are seriously
planning change, but not within the next 30 days are "contemplators".

Preparation Stage: Those individuals who are planning behavior change and are planning to do so
in the next 30 days are in the "preparation" stage.

Action Stage: Those individuals who have answered positively to the above questions and also
indicate that they have already made behavior changes to improve lipids or their health
status but have done so for less than six months are in the "action" stage.

Maintenance Stage: Those individuals who have sustained their behavior change over six months
are in the "maintenance" stage.

 

 

Figure 3: EVALUATION OF CLIENT'S "STAGE OF CHANGE" ACCORDING TO THE
TRANSTHEORETICAL MODEL OF BEHAVIOR CHANGE

Adapted from: C. Cassidy, 1997

Change Process

14

Interventions

£31395.

 

Consciousness Raising: acquisition of
information about health behavior change

Self Liberation: Choosing between be-
haviors

Social Liberation: when individuals
begin to notice social consequences of
continued unhealthy behavior

Self Reevaluation: when individuals assess
how they feel about a behavior

Counterconditioning: substitution of
activities to fill void of old behavior

Stimulus Control: remove stimuli of
old behavior & add new ones

Contingency Management: rewarding
desired behaviors

Catharsis: expressing emotions related
to their behavior change

Helping Relationships: professional or
supportive social networks that assist
individual to change

Provide personalized information Precontemplation

about illness & desired behavior
changes

Provide feedback on prior

changes in client's life

Encourage identification of
social pressures toward pos-
itive health behaviors

Values clarification exercises b/t
desired & current behavior

Teach relaxation exercises

Help identify triggers to old
behavior, remove stimuli

Assist client to identify re-
wards for new behaviors

Encourage clients to express
feelings about change

Help identify support that
will encourage behavior change

Contemplation

Precontemplation
Contemplation
Preparation

Contemplation
Preparation

Contemplation
Preparation

Preparation
Action

Preparation, Act-
ion, Maintenance

Preparation, Act-
ion, Maintenance

Contemplation,
Preparation
Action

Preparation, Act-
ion, Maintenance

 

Figure 4: ASSISTING HEALTH BEHAVIOR CHANGE

Adapted from V. Conn, 1994

Chapter 2
LITERATURE REVIEW

A review of the existing literature related to lipid programs based on the NCEP
guidelines leads to the conclusion that these guidelines are effective in decreasing risk for
the development of heart disease. Review of existing literature in relation to the
advanced practice nurses in primary care and illness prevention has also shown that the
role is both effective and cost efficient. There is limited, though supportive research

available on the use of an APN as a leadership role within a lipid program.

LIPID PROGRAMS

Lipid clinics were initially developed in the 1960's and existed virtually only in
large university settings (Ziakja, 1995). However, since the development of the National
Cholesterol Education Program guidelines in 1988, and revised in 1993, there has been a
considerable interest in treating dyslipidemias (Ziakja, 1995). According to A. Brown MD
of the Midwest Heart Lipid Clinic, the current trend is to treat dyslipidemias before heart
events have taken place, thereby significantly decreasing the incidence of the number one
health problem in the United States (Brown, 1996). This thought is also reflected in an
article by S. Grundy MD (1997), who optimistically speculates that the let century will
be the end of heart disease as it is currently known. He asserts that only through primary
prevention will this drastic change take place. He also fully supports the NCEP guidelines
as a basis for treatment of dyslipidemias.

According to several sources the utilization of APN's in lipid programs is effective,

cost efficient and provides a high level of patient satisfaction (Brown, 1996; Cofer, 1996;

15

16

Rudd, I994; Ziakja, 1995). Patient satisfaction has been an important outcome
measurement, studies have shown that "patients that are more involved in their care and
are more satisfied are more likely to comply with treatment plans" (Naylor, 1991, p. 213).
Cost effectiveness has been proven in existing clinics, as APN's tend to generate revenue

similar to that of a physician at a fraction of the cost in terms of salary (Ziakja, 1995).

APN ROLE

Access to high quality, cost effective healthcare has become a major issue for both
governmental agencies and the public sector. Pursuit of this care has led to the concept of
"primary care". Several definitions of primary care exists in current health care literature.
According to Al. O'Flynn (1996), one definition of primary care "is a provider-driven
health care that focuses on aspects of gatekeeper, continuity, prevention, promotion,
treatment, and referral when appropriate" (p. 431). On the other hand, I. Goeppinger
(1996) (while acknowledging multiple definitions), states "Primary care has continued to
mean a basic level of healthcare usually provided in an outpatient setting, that emphasizes
a patient's general health needs. The most frequently emphasized aspects are first-contact
professional care that is accessible, comprehensive, coordinated, continuous and
accountable" (p. 65). The latter definition was also utilized in a landmark article regarding
the APN role by BJ. Safriet, in the XalelQumalfiflkegulafiQn in 1992. Yet another,
more holistic, definition of primary care that includes the concept of community,
developed by the Institute of Medicine interim report is "the provision of integrated,
accessible healthcare services by clinicians who are accountable for addressing a large
majority of personal healthcare needs, developing a sustained partnership with patients,
and practicing in the contexts of family and community" (Venegoni, 1996, p. 255). A
less acceptable, though popular definition of "primary care" is the "usual source of care"

according to J. Goeppinger (1996, p.65).

17

"Wellness" or "absence of illness" are major goals in today's healthcare system.
Almost all literature regarding the role of the APN includes emphasis on health promotion
and illness prevention. An article that discusses the APN and physician assistants as
"physician substitutes" notes that APN productivity is not only acceptable, but that APN's
have the added benefit of "other services, including prevention, patient education and
counseling" (Schefiler et al, 1996, p. 213). Another author refers to the APN role more
adeptly, "NP's have personal contact with individuals, families, groups, and other members
of the interdisciplinary team. They provide primary healthcare that emphasizes health
promotion, disease prevention, early detection, diagnosis, prescription, and
implementation of a course of treatment” (Berger et al, 1996, p. 253).

Attempts to control skyrocketing costs in the delivery of healthcare have led to
prospective payment programs leading to the concept of "managed care systems". It is of
interest that managed care has become a major trend in the United States, and that both
advanced practice nursing and this system of care share similar principles. While major
goals of the current healthcare system includes cost containment and quality care,
managed care systems focus on "indicators" to ensure quality (Satinsky, 1996). The
Health Care Advisory Board has identified quality indicators when evaluating contracted
providers, these include: access to care, appropriateness of care, patient's perception of
care, outcome measures, disease management, prevention measures, and enrollee health
status measures (Satinsky, 1996). M.I. Satinsky (1996) also believes that by nature of
APN training, combined with knowledge of managed care APN's are in an ideal position
to assume a variety of important roles. In discussing the current status of healthcare
delivery, including managed care, A.|. O'Flynn (1996) states "Advanced practice nurses
are the best choice to meet the needs in the most cost effective, holistic manner, while
empowering the patient, family, and community in gaining greater control over their
health... the past 30 years have taught us that promotion, prevention, and early

intervention are cost effective in the long run” (p. 430).

18

Numerous approaches to decrease out-of-control healthcare expenditures have
been proposed, including that of managed care. Cost effectiveness is a frequently
recurring theme in today's healthcare arena. Fortunately, multiple studies indicate that the
use of APN's in primary care provides both high quality care and cost effectiveness
(Safriet, 1992). Two sources cite results of studies that compare outcome evaluations of
physicians versus APN's and concluded that APN's scored as well as physicians in
provision of healthcare delivery and scored better in areas of patient satisfaction, patient
communication and preventive care (Fitzgerald & Wood, 1997; O'Flynn, 1996). Provision
of care by an APN has shown to be cost effective related to a decreased costs in
comparison with that of a physician. These costs are saved when taking into account
education costs, salaries and benefits (Safriet, 1992).

AG. Gift (1994) fiirther explains costs when evaluating APN-run primary care
programs. Her definition of "costs" takes into account the expenses that are involved in
program delivery. She describes "direct costs" as those expenses directly related to
delivering the program being offered, including salaries and benefits provided for those
involved. On the other hand, "indirect costs" are those not directly related to delivering
the specific program but rather those resulting from services that are shared by many
departments in an institution. In those programs that generate revenue, a comparison of
both indirect and direct costs compared with revenue generated will give the best
indicator of cost effectiveness. These factors will be important in the development and
evaluation of the lipid program.

The ability to demonstrate quantifiable outcomes is essential to justify the
utilization of APN's over other healthcare providers. Outcome measures are important
indicators of healthcare effectiveness and quality and are also essential to the
advancement of nursing as a science (Harris & Warren, 1995). While authors seem to
agree on the critical need for "standardized, retrievable data collected by nurses", they

also acknowledge the difficulty in devising assessment tools and a documentation process

19

that is universal in nursing (Harris & Warren, 1995; Nugent & Lambert, 1997). Nursing
researchers also agree that the traditional outcome measures-- patient mortality, morbidity,
and patient length of stay, are not appropriate and significantly limit evaluation of APN
outcomes (Harris & Warren, 1995; Naylor et al, 1991; Nugent & Lambert, 1997).
Proposed outcome measures that reflect APN interventions have been proposed, these
variables include fiinctional status, mental status, stress level, satisfaction with care,
burden of care and cost of care (Naylor et al, 1994; Nugent & Lambert, 1997).

According to Nugent & Lambert (1997) these indicators may be appropriate in
some circumstances, they will not be applicable in all cases. For instance, clinical
outcomes will need to be evaluated in the lipid program and must be included as a portion
of the APN interventions. Functional status and mental status will unlikely be included in
clients' outcome measurements in the lipid program. Furthermore, assessing the "cost" to
the client is fairly straight forward, while evaluating effectiveness of an intervention can be
far more difficult. Problems with evaluating effectiveness of interventions were described
by Nugent & Lambert (1997): the most frequently used outcomes are relatively
insensitive, occurring infrequently; final outcomes are frequently unknown until long afier
the provider no longer has contact with the patient; outcomes can be influenced by factors
outside the control of the healthcare system; information about many outcomes is not
readily available in the clinical records; and few lists of valid effectiveness criteria and
measurement methods exist.

Healthcare providers who excel in assisting individuals with behavior change play
an important role in today's healthcare. The APN as a change agent is well documented
and supported in the literature. There is also substantial information about APN's use of
the Transtheoretical Model of Change as the basis for APN interventions. In a study that
utilized nurses as educators and Counselors in smoking cessation, with interventions based
on this "stage based" model, Hecht et al (1994) established that nursing interventions had

a major impact on behavior change (smoking cessation) when utilizing a "team approach".

In an interesting article by VL. Champion (1994), the Health Belief Model and the
Transtheoretical Model were combined in an attempt to predict and improve the use of
mammography for cancer detection. This was the only study that combined two
approaches that was reviewed. While it appeared to be a useful combination in predicting
behavior change based on "perception of severity of illness" and stage of change, the study
acknowledges significant limitations including sample size, lack of cultural variation, and
lack of financial diversity. Though limited, it does provide support for fiirther research in
these areas combining conceptual and theoretical frameworks. V.S. Conn (1994) clearly
supports the APN as the "ideal health care provider to deal with health behavior change",
based on APN subroles (clinician, educator, consultant, researcher, and administrator) and
interventions utilized in the Transtheoretical Model (p. 192).

The teaching role of the APN is of utmost importance when attempting to
influence behavior change. According to BK. Redman & S.A. Thomas (1992), patient
teaching "is an interpersonal intervention that uses stimuli in the environment or creates
new ones to help the patient develop new thoughts, skills, attitudes, intentions and feelings
of self efficacy, usually in combination, that are permanent enough to be usefiil in
behavioral change" (p. 304). In an article by AM. Berger et al (1996), it concludes that
the teaching skills of the MSN prepared APN are superior to those nurses with less
education, thus fiirther supporting their view of the "expert educator" role of the APN.

An article by Scheffler et al (1996) points out that the role as educator and counselor that
sets the APN apart from other health care providers (physicians and physician assistants).
The review of literature fiilly supports the teaching role as a unique and essential aspect of
behavior change.

The APN role as a counselor encompasses many education principles. It is
"goal-directed", but focuses on emotional support in the APN-client relationship. In the
role as counselor the APN helps the client focus on feelings and behaviors that have

interfered with usual adoptive behavior (Bulachek & McCloskey, 1992). This role is often

referred to as the "helping role" in APN literature (Fenton, 1993; Hixon, 1996). It is this
component of APN intervention that has been linked with higher levels of patient
satisfaction in some studies. As described by Naylor et al (1991), "Higher levels of
satisfaction with care have been associated with providers or institutions that make care
more 'personal'. Good communication skills, empathy. and caring are important predictors
of patient satisfaction” (p. 213).

A team approach will be utilized to improve client health status. According to
King et al (1996), collaboration is described as "nurses and physicians collaboratively
working together, sharing responsibilities for solving problems and making decisions to
formulate and carry out plans for patient care" (p. 148). The purpose of collaboration is
to enhance patient outcomes that may not occur if services were provided by one provider
alone (King, 1996). This belief is also reiterated by K. Jones (1993) who advocates
collaboration among health care disciplines stating "no one professional group operates
independent in the delivery of services to patients" (p. 149). A1. O'Flynn (1996) believes
that APN's function at their firllest extent when working in collaboration with physicians
and other healthcare professionals as a firnctioning interdisciplinary team.

The role as clinician is a significant role in the lipid program. Studies have
conclusively shown that APN's clinical care that includes diagnostic tests, interpersonal
management, thoroughness of diagnosis and treatment documentation as well as outcome
measures are comparable if not better than that of a physician, except in areas that
required technical solutions (Safiiet, 1992). According to P. Ziakja ( 1995) the APN is

qualified to handle the vast majority of clinical care in the lipid program.

Chapter 3
PROJECT DEVELOPMENT

The Promed Lipid Modification Program will be based on the National Cholesterol
Education Program, Adult Treatment Panel II, guidelines made available in 1993 (See
Table 1). LDL cholesterol is the lipid most commonly associated with the development of
coronary artery disease, however, very low levels of HDL cholesterol, or elevated levels
of triglycerides have also been associated with the development of CAD. These lipid
abnormalities, along with other risk factors can increase the likelihood of coronary artery
disease development (See Table 2).

Development of the lipid program at Promed Family Practice will begin with a
pilot phase. During this phase, a small number of clients (approximately 50), will be
identified prior to opening the option to all clients with dyslipidemia. During this time,
procedures including initial evaluation, dietary intervention, goal setting, medical
intervention, follow up and patient feedback will be monitored and adjusted according to

client, staff and outcome evaluations.

23

Table 1

Treatment Decisions Based on LDL-Cholesterol Level

 

 

Initiation Level LDL Goal
Dietaulherapx
Without CHD and with fewer than two
risk factors 2 160 mg/dL < 160 mg/dL
Without CHD and with two or more
risk factors 2 130 mg/dL < 130 mg/dL
With CHD 2 100 mg/dL S 100 mg/dL
nglherapy * l
Without C HD and with fewer than two
risk factors 3 190 mg/dL < 160 mg/dL
Without CHD and with two or more
risk factors 2 160 mg/dL > 130 mg/dL
With CHD 2 130 mg/dL** £100 mg/dL

* If an initial trial of dietary therapy has not been adequate, drug therapy should be added
to dietary therapy, not substituted for it.

** In CHD patients with LDL-cholesterol 100-129 mg/dL, provider should exercise
clinical judgment in deciding whether to initiate drug treatment.

Adapted from NCEP, I993.

 

 

Table 2
Risk Factors for Heart Disease Other than LDL Cholesterol
13 . . , B' I E -
Age: Male 2 45 years Diabetes mellitus

Female _>_ 55 years or premature
menopause without estrogen
replacement therapy Current cigarette smoking

Family history of premature CAD

(definite myocardial infarction or

sudden death before age 55 in male Low HDL cholesterol (<35 mg/dL)
or before age 65 in female first-degree

relatives)

Hypertension
(blood pressure 2 140/90 mm Hg
or on antihypertensive medication)

 

II 'B'IE

 

High HDL cholesterol

(if HDL cholesterol is Z 60 mg/dL
subtract one risk factor because
high HDL Cholesterol levels are
associated with lower CHD risk)

Based on the 1993 Adult Treatment Panel 11 Report of the National Cholesterol Education
Program (NCEP).

CLINIC PERSONNEL

Prior to the implementation of the lipid program at Promed Family Practice,
personnel must be designated to cany out certain tasks. While these positions may be
adjusted as the pilot program progresses, an overview of job responsibilities are as
follows.

The clinic director will be an APN certified as a Family Nurse Practitioner. Clinic
director responsibilities will include development, organization, coordination and
management of the lipid clinic. The director will also direct and participate in patient
assessment, patient treatment, education, and promote the program to both other
providers and the patient population.

The program will have a medical director. This person is a board certified
internist. Duties and responsibilities will include participation in physical assessment, lipid
program development, organization, and problem solving with the APN and dietitian for
clients with severe dyslipidemias.

The dietitian involved in the lipid program will have extensive knowledge and
experience with the NC EP recommendations. She will be responsible for nutritional
assessment and evaluation, and expected to be knowledgeable in relevant cultural
differences in diet. Education regarding the NCEP Step I or Step II diet (See Table 3), or
more fat restricted diets, will take place through one-on—one counseling and in special
classes designed for the lipid clinic participants.

The executive director is an individual from Promed administration who will
oversee the financial aspects involved in this program. As the program is not anticipated
to generate firnds initially, the advantages to the practice through marketing to the HMO’s
and private insurances will be pursued and evaluated.

The clinic director, dietitian, and medical director will work together in developing

policies and procedures and in refining the lipid program. The clinic director, medical

director and executive director will prepare and maintain a budget, equipment, supplies,
and staffing needs.

Clients will enroll voluntarily and will need to contact their insurance regarding
coverage. While participating HMO’s and Medicare guidelines will be familiar to our
clinic, private insurance will need to be contacted by the client. Any uncovered costs are
expected to be paid for by the client. Close adherence to guidelines for reimbursement
will be monitored within the clinic. Reimbursement should not be a major issue, as the
program emphasizes illness prevention (CAD) and dyslipidemia codes exist based on

NCEP guidelines.

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CLINIC PROCESS

Enrollment into the Promed Lipid Modification Program will be based on NCEP
recommendations. Guidelines determining which treatment protocol will be used are
based on level of dyslipidemia and other risk factors. Although this is a prevention
focused program, these clients must have some aspect of diagnosed dyslipidemia, such as
elevated LDL cholesterol, low HDL cholesterol, elevated triglycerides or two or more risk
factors associated with the development of CAD (See Figure 5). For those patients that
already have existing coronary heart disease, a second guideline has been developed due
to more stringent goals on LDL cholesterol (See Figure 6).

Once clients have enrolled in the Promed Lipid Modification Program, they will
begin the program process. Algorithms that focus on APN interventions in the program
have been developed. The algorithms that focus on the group without heart disease varies
somewhat from the heart disease algorithm due to differences in LDL cholesterol goals
(See Figures 7 & 8).

After review oftheir medical history, all patients will receive a physical exam that
focuses on CAD. Emphasis will focus on retinal exams, carotid auscultation, heart
evaluation, pulmonary system, peripheral vascular system, electrocardiogram, and will also
include inspection for tendon xanthomas, or other overt signs of cholesterol deposition.
Clients who have established coronary artery disease or who have several risk factors
along with sedentary lifestyles will have an exercise stress test scheduled through the
Promed office or with a participating cardiologist office.

Initial visits will include the introduction and review of NCEP guidelines. Clients
will be encouraged to discuss their lipid goals and will be given a binder that they are
expected to bring to the following visits. The binder will provide various cholesterol
information, a chart to keep track of their own progress towards goals and a chart to keep
track of exercise and dietary intake. The stage of change will be evaluated during

contacts, in the office or via phone. Interventions will be based on their current "stage" of

29

change, and may include additional office visits with either the APN, physician or dietitian,
along with more frequent phone support, or special classes that may be available (e. g.
low-fat, low-cholesterol cooking class). Attempts will be made to evaluate and educate at
every intervention.

At the end of the initial visit, goal setting will be introduced. Clients will give
feedback on what they feel is realistic when beginning the cholesterol reduction process.
This may include activity goals e. g.. "I will walk one mile, three times weekly", or dietary
goals e. g.. "I will start reading labels and pay attention to fat content." The APN will give
feedback on goals and help set priorities. It is important to consider patient goals and
direct them to appropriate and reachable endpoints. These goals will be entered into
clients’ charts and their personal binder. Clients will be instructed to keep a three-day
dietary diary for the following visit.

At the dietitian visit, the content of the diet diary will be discussed, and focus will
be on needed changes in dietary habits. The "body mass index” method will be utilized to
guide weight management (See Appendix A). A diet prescription will be developed based
on their diet diary, BMI, and NCEP guidelines. The dietitian will schedule a follow-up
visit with those clients who will be making significant dietary changes or those who may
need more frequent interventions based on their stage of behavior change.

Phone calls to check progress towards current goals will take place every two
weeks during the first 3-6 months of the program. Phone contacts will focus on stage of
behavior change, barriers to change and questions regarding the lipid modification
process. Interventions appropriate to the stage of change and patient goals will be
discussed and encouraged. Clients who are having difficulty with behavior changes may
benefit from an office visit with either the APN, physician or dietitian.

Follow—up visits will focus on lipid evaluations and progress towards goals.
Because some patients may be attempting several behavior changes simultaneously, some

change stages may not be identical. For instance, a patient may be following a Step I diet

30

closely, but may not be exercising. Interventions may have a different type of focus for
each goal. Follow up visits may include meetings with the dietitian if patients need further
teaching, new diet prescription, or had weight-loss as one of their goals. If medications
have been added, side effects and compliance with medical regimens will also be included.
Clients who have started pharmaceutical intervention and those who have heart disease or
several risk factors also may need more frequent interventions either in the office or via

phone.

31

Lipoprotein analysis

fasting, 9-12 hours

(may follow a total cholesterol

determination or may be done

at the outset)

F— Repeat total cholesterol and

Desirable HDL-cholesterol measurement
LDL-cholesterol within 5 years

<13O mg/dL

HDL >35 mg/dL Provide education on general
TG <200 mg/dL population eating pattern,

 

physical activity, and
risk factor reduction

 

 

Borderline-high-risk Provide information on the
LDL-cholesterol Step I Diet and physical activity
130-159 mg/dL and with )
fewer than 2 risk factors Reevaluate patient status
HDL >35 annually, including risk factor
TG <200 reduction

«Repeat lipoprotcin

attalvsis

I 30- I 59 mg/dL* and W'Ith ~Rcinf'orce nutritition and
2 or more IISk factors physical acIi\it) education
HDL <35
TG <200

Refer to Lipid Program

. See Algorithm

High-risk
LDL-cholesterol
_>_ 160 mg/dL*
HDL <35

TG >200

‘ On the basis ot‘tlte average nfmn determinations. If'thc first two I.I)I .{ltrrlcstcrnl tests differ b} more than 30 mgdl .. a third test should
he obtained \\ ithrn 1-8 weeks and the average value ol'thrcc tests used.

Figure 5: PRIMARY PREVENTION IN ADULTS WITHOUT EVIDENCE OF CHD:
CLASSIFICATION BASED ON LIPID PROFILE

Adapted from: NCEP Guidelines, 1993

32

Lipoprotein analysis“
fasting, 9-12 hours

Average of .2 measurements
1-8 weeks part”

 

Optimal '— Individualize instruction on
LDL-cholesterol diet and physical activity
5100 mg/dL level
HDL >60
TG<200 Repeat lip0protein analysis
annually, after maintenance of
L. profile every 6 months x 2 years

 

Higher than optimal Refer to Lipid Modification Program
LDL-cholesterol __——§ See Algorithm

>100 mg/dL

or HDL <35

or TG >200

' Lipoprotein analysis should be performed when the patient is not in the recovery phase from an acute coronary or other medical event
that would lower their usual LDlrcholestcrol level.

“ Il'the first two LDL-cholesterol tests differ by more than 30 mg'dL, a third test should be obtained within 1-8 weeks and the average
value ol'the three tests used.

Figure 6: SECONDARY PREVENTION IN ADULTS WITH EVIDENCE OF CHD:
CLASSIFICATION BASED ON LIPID PROFILE

Adapted from: NCEP Guidelines, 1993

33

 

 

 

 

 

 

 

I‘m Protocol I
LDL '~ [30
lll)l. ; 35
Initial Visit
(see text)
Dietary Consult
b
2-week “S'upport Call”
Reevaluation of lipids
(4 weeks p start ot'dict)
6 W
Elm Eleni!
Improved Unchanged
office visit (O.V.) office visit (O.V.)
meet with dietitian
t
q 2 week "Support Call” 1-2 week “Support Call"
x 5 x 4 weeks
with inten‘entions pm
9 v
Reevaluate “ka Reevaluate lipids
at 12 weeks at 2 mos; on Rx diet
Corrt'mued Worserfing or Ingroved Worsemng
improvement or Unchanged Follow Plan A or Unchanged
lipid goals met lipirh/bdtavior (may need more flu or meet w/
. calls. 0.V., etc.) dietitian.
q 24 week follow Plan B) APN or MD
“Support Call” Step I! dict
q 3 mg. O.V. “SupQCalls”
lipids q 6 mos. q [-2 weeks
x 1 year, then i
annually Rees Iuate lipids at
(deterioration of 4 weeks on new diet
lipids -— > Plan B) '
Imprinted Wars! or
Follow Plan A Unchanged
Cautiously O. V.
COIBILEI' Medicine
“Support all” q [-2
weeks x 4-8 weeks
RaIaluate lipids
In oved Woé or
Continue tx acmrding Unchanged
to reeommendatbn & adjust Rx
Plan A cautiously change Rx at
8-12 week intervals
I
Improved “Support (fire:
Monitor as t).\'., \n'u based on
directed per Rx the individual
Plan A When

appropriate

l.l)l. lttll
HDL 2‘ 35

Improved
0. V.

O
q 2-week
“Support
Calls"

V
Reevaluate
lipids
l2 wks

Improved
or
Stable

q 6 mos.

Improved
LDL < loo
0. V.

i
q 2 :eek “Support Call"

Reevaluate lipids
8 wwks

Worsening
of lipids
O. V.
meet wi dietitian

q 2 week
“Support Call” x4
V
Reevaluate lipids

Worse
0.V.

(Follow meet w/

Plan A) APN

' (Follow

Plan 8)

Improved
O. V'.

lipids & t). V.

x 2 years

then annually~

Figure 8: Algorithm for patients with established CHD

34

Protocol II

Initial visit

6

Dietary Consult
q l-week "Support Call"

Reevaluatinn oflipids
(4 weeks p start ol‘dict)

 

6

ma

I,‘nchanged
LDL IOO- l 30
0. V.
v

0.V. (see text)
V

q I-2 “Support Call”
it" 8 weeks

i

Rw'aluate lipirk

 

4
Noéhange Worse

 

Improved
0. V. 0.V. 0.V.
Follow meet wz’ Follow
Plan A dietitian Plan C
q l-2*week
“Support
Call"
+
Reevaluate lipids
at 2 mos.
lmtroved Worse
Follow Plan 0. V.
A cautiously Follow
Plan C

1

m5:

Worsened
LDL > 130
O. V.

meet w/ dietitian,

APN

LDL 3' I60 Prescribe Rx

q t-2 weak “Support Call"

include Rxeval.

o

 

Reevaluate lipids
Improved No Change Worse
0.V. 0.V. Refer
V adjust or *
q l-Z week add Rx Endocrinology
“Support med w/ l or
Call" APN or Cardiology
0.V. as dietitian
directed
q I-2 week
“Support Call”
0
Reevaluate lipids
as directed per Rx
i 0
Improved No Change
0.V. or Worse
Follow 0.V.
Plan A or B Continue
Plan C

35

PATIENT CRITERIA

The development of a lipid modification program within a primary practice office
stems from necessity and prevalence of managed care within the healthcare system. In a
large practice, a part-time lipid clinic could easily be supported with their patient
population (Brown, 1996; Ziakja, 1995). The client population will be adults over twenty
years of age. The NCEP guidelines recommend screening at twenty years old, however,
young adults who have had high cholesterol found incidentally on laboratory tests, or
those at high risk due to family history may be included at a younger age. Most
medication regimens are not utilized in young age groups, however, aggressive dietary and
exercise regimens would be indicated to improve already elevated cholesterols. Very
young persons (school age) at high risk due to familial dyslipidemias will probably be
referred to a university-run lipid clinic due to the high atherogenicity of these
dyslipidemias. Clients will have some aspect of dyslipidemia, including an LDL >130, an
HDL <35 or triglycerides >200mg. It is of note that elevated triglycerides are poorly
understood in relation to the development of CAD. However, they have been found to be
correlated with the development of CAD when found in conjunction with low HDL’s.
Clients already in the lipid modification process will be accepted if referred for treatment,
but the primary provider will need to waive further cholesterol interventions to the lipid

clinic.

36

RATIONALE

Multiple studies indicate dyslipidemia is a risk factor for the development of heart
disease in adults (NCEP, 1993; Braunwald, 1997). Therefore adults with abnormal lipids
were the chosen population. By taking active measures to reduce or improve lipids, the
associated risk of athlerosclerosis can be significantly decreased. Patient education
regarding dyslipidemia and heart disease is imperative to preventive medicine. Legal
ramifications must also be considered as national guidelines exist for the treatment of
dyslipidemias. If providers do not follow or ignore dyslipidemia, they may be found
neglectful for lack of treatment.

The implementation of a lipid program is not without financial risk. However,
health prevention programs are of particular interest to managed care systems that focus
on illness prevention and include a considerable percentage of the client base. While this is
a wellness-focused program, the clients in the clinic must have some element of
dyslipidemia to participate, and “dyslipidemia” is a billable CPT code. Therefore, private
insurance participants are likely to have coverage for services. Educational grants from
pharmaceutical companies are also anticipated to help defray costs related to patient
information, lipid monitoring sofiware, as well as educational opportunities for lipid
program staff. Utilization of an APN in the clinic also decreases costs due to the
difference in salary compared to the physician providers.

Voluntary enrollment and participation is necessary for the theoretical framework
and the program to be successful. Patients will be expected to take an active role in their
lipid therapy and decision making. For those patients who refuse enrollment or who are

noncompliant, documentation must be in their chart regarding intervention offered.

37

EVALUATION

Evaluation of the lipid clinic will be performed by an outside firm who has
developed an evaluation system based on the NCEP guidelines. This is result of an
educational grant by Merke, Sharpe & Dohme. The consulting firm will do a preliminary
review based on diagnostic codes that include heart disease, congestive heart failure and
dyslipidemia. They will look at lipid profiles, treatment, whether treatment is according to
NCEP guidelines, along with appropriate follow up and evaluation of lipid outcomes.
They will be looking at providers individually and as a group. Evaluation after the
implementation of the lipid program will be based on the same criteria, and will evaluate
program versus nonprogram patients.

While improvement in lipid levels and reduction of coronary artery disease is the
overall goal of the program, evaluation of outcomes specifically related to APN
interventions is also necessary. The demonstration of APN effectiveness and cost
efiiciency is important, as this information is also essential to the advancement of nursing
as a science. Unfortunately, tools that assess APN interventions are limited. They lack a
universal language which makes documentation of outcomes difficult. The development
of a tool that can measure APN interventions in an outpatient program would be
beneficial.

In a lipid program, APN interventions that should be evaluated include: patient
satisfaction and cost of care. Patient satisfaction is an important indicator for quality
carein an article by MD. Naylor et al, they state that "Good communication skills,
empathy, and caring are important predictors of patient satisfaction" (Naylor et al, 1991 p.
213). [n the same article they refer to a study by Greenfield et al, that concludes "Patients
who are involved in their care and are more satisfied with care are more likely to comply
with treatment plans" (Naylor et al, 1991, p.213). If these statements are true, and the
APN interventions are effective, clients can be expected to be successful in behavior

change and thereby meet the overall goals of the clinic. Patient satisfaction indicators

38

would include those interventions that the APN had carried out, such as education,

follow-up phone calls, accessibility to clients, etc

PILOT MATERIALS

Prior to the implementation of the lipid program, patient files, documentation,
patient education materials must all be devised for APN interventions. Evaluation of
frequent procedures, laboratory tests, paperwork, etc, must be considered prior to the
introduction of the program . NCEP guidelines and intervention algorithms are examples
of guidelines needed prior to opening the pilot phase. Other pilot materials include the
initial history filled out by the patient that is periodically updated throughout their
participation in the program (See Appendix B). A flowchart that monitors patient visits,
laboratory values, coexisting risk factors, lipid results, exercise and dietary goals,
medications, education materials will also be a part of the patient's chart (See Appendix
C). Numerous patient education materials will be utilized, they will follow similar formats.
Patients will be instructed to keep this information in their lipid binder for reference (See
Appendix D). Frequently used letters regarding results, reminders for lab work, will also
be utilized (See Appendix E). Memos to facilitate correspondence with primary providers

have also been developed (See Appendix F).

Chapter 4

Implications for Practice

The development and implementation of the APN role in a lipid program within a
primary care practice is a huge but exciting challenge for advanced practice nursing. The
ability to impact favorably on the nation's number one health problem is well within the
APN realm. Emphasis on health promotion is inherent in the advanced practice role and a
very large element of the lipid program. Multiple APN roles will be encompassed in the
planning, development, implementation and evaluation processes.

Marketing the lipid program will be an important aspect of a successful program.
Following the implementation of the program, it can be marketed to othe practices within
the community, and could be marketed to other advanced practice nurses to help them
develop similar programs. The ability to act as a clinical consultant to other providers,
practices and APN’s will also help promote the lipid program.

Being a positive role model in the practice and the community is important for
advanced practice nursing. In this quickly expanding field, it is important for advanced
practitioners to undertake endeavors that will set them apart in a positive fashion from
other health care providers. Advanced practitioners should also strive to be role models
for other nurses and nursing students at any level. Being a role model in the lipid clinic is
also very important, as problem solving to achieve dietary and activity goals may arise
from the provider's personal experience.

Being a patient advocate is always an important role for any level of nursing
(Berger et al, 1996). Cost is often problematic in the treatment of dyslipidemia, and could
pose a considerable obstacle for patients without insurance or prescription coverage.

While ideally lower cost products could be utilized, strategies to ensure treatment without

39

40

financial hardship must be attempted. Financial burden could adversely affect both
compliance and health status. Possibilities that may decrease barriers in regards to cost
and compliance include the addition of group classes that will help disperse costs; support
groups that help with problem-solving for clients struggling with behavior changes or
regularly scheduled special classes that focus on various aspects of desired behaviors such
as exercise, cooking, eating out, etc.

The APN role in the delivery of primary care is essential. Concepts identified in
primary care include comprehensive, coordinated, accessible care that is focused on early
detection, health promotion and prevention of illness (O'Flynn, I996). Goals of the
current healthcare system include the provision of high quality primary care that is also
cost effective. Advanced practice nurses have been identified as the ideal healthcare
providers to fill many primary care needs (Conn, I994; Safriet, 1992).

Because the largest expenditures in healthcare are lifestyle induced (eg. lung
disease, heart disease) behavior change is a major focus of APN interventions (O'Flynn,
1996). According to Conn "the healthcare provider who develops excellence in healthcare
behavior change will play an important role in healthcare delivery" (Conn, 1994). She also
identifies the APN as the "ideal" healthcare provider to deal with health behavior change
(Conn, I994). It is imperative that APN's take this opportunity to promote their
uniqueness and strengths among other healthcare providers. For this reason, the concept
of outcomes measurement becomes particularly important. Outcome measures can
provide concrete evidence that APN interventions are not only effective and cost efficient,

but also associated with high degrees of client satisfaction.

APPENDIX A

41

Appendix A

Nomogram for Determining Body Mass Index (Bray, 1978)

VVEICHIT'
KG LU

:50
I40
ISO

020

IIU

40

U
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APPENDIX B

42

Appendix B
Sample Cardiac Focused History

PROMED LIPID MODIFICATION PROGRAM
7901 Angling Road
Portage, MI 49024
(616) 324-8600

Enrollment Questionnaire

 

 

 

 

 

 

 

 

 

 

 

NAME: DATE:
SS#: DATE OF BIRTH:
OCCUPATION:
MEDICAL HISTORY:
1. Do you take any medication on a regular basis?
YES NO W
M.
Medication Dascfmg) Ezequency Ware
1.
2.
3.
4.
5.
6.
2. Have you ever taken medication to improve your cholesterol level?

_ YES __ NO
If yes, which one(s)?

3. Do you have any allergies? _ YES _ NO
Ifyes, please list them with type of reaction:

 

 

4. Please indicate whether or not you have or have had any
of the following conditions:

High Cholesterol _ YES _ NO
High Triglycerides _ YES _ NO

High Blood Pressure (Hypertension) _ YES _ NO
Coronary Artery Disease _ YES _ NO
Heart Attack Date _ YES _ NO
Bypass Surgery Date _ YES _ NO
Angioplasty Date __ YES __ NO
Atherectomy Date __ YES _ NO
Peripheral Vascular Disease _ YES _ NO
Stroke __ YES _ NO
Aneurysm (bulging arterial wall) _ YES _ NO
Diabetes _ YES _ NO
Thyroid disease or problem __ YES _ NO
Kidney disease _ YES _ NO
Liver disease or jaundice _ YES _ NO
Gall Bladder Disease _ YES _ NO
Gout __ YES _ NO
Peptic Ulcer _ YES _ NO
Intestinal problems (colitis, etc.) _ YES _ NO
Glaucoma _ YES _ NO

5. Women, have you had a hysterectomy? __ YES _ NO
Are you post-menopausal _ YES _ NO
Do you take any hormone supplement? __ YES __ NO

RISK FACTOR ASSESSMENT:

6. Are you a smoker? _ EX _ YES _ NO
If yes or ex: How much do (or did) you smoke per day?
How long have (or had) you been smoking?
How long ago did you quit smoking?

7. Has your father had any of the following conditions?
Stroke (est. age _) _YES _NO _Not sure
Heart Attack (est. age __) _YES _NO _Not sure
Bypass surgery (est. age __) _YES _NO _Not sure
Angioplasty (est. age __) _YES __NO _Not sure
Leg pain when walking

(Int. Claud.) _YES _NO _Not sure

Coronary Artery Disease _YES __NO _Not sure
High Cholesterol _YES __NO __Not sure
High Triglycerides _YES _NO _Not sure

8. Has your mother had any of the following conditions?

43

Stroke (est. age ) _YES _NO _Not sure

10.

ll.

12.

44

Heart Attack (est. age _) _YES _NO _Not sure
Bypass surgery (est. age __) _YES _NO _Not sure
Angioplasty (est. age __) _YES _NO _Not sure
Leg pain when walking

(Int. Claud.) _YES _NO _Not sure
Coronary Artery Disease _YES _NO _Not sure
High Cholesterol _YES _NO _Not sure
High Triglycerides _YES _NO _Not sure
Has your hmlhemLsisIeI had any of the following
conditions?
Stroke (est. age _) _YES _NO _Not sure
Heart Attack (est. age __) _YES _NO _Not sure
Bypass surgery (est. age _) _YES _NO _Not sure
Angioplasty (est. age _) _YES _NO _Not sure
Leg pain when walking

(Int. Claud.) _YES _NO _Not sure
Coronary Artery Disease _YES __NO _Not sure
High Cholesterol _YES _NO _Not sure
High Triglycerides _YES _NO _Not sure

Since problematic cholesterol levels are often
inherited, please complete the following:

NamefalnfichildftenlABECthestemllesLDQne

YES __NO _Not sure

 

YES _NO _Not sure

 

_YES _NO _Not sure

 

__YES _NO _Not sure

 

Describe the type and amount of exercise you do
regularly:

Do you have any pain when walking? _ Yes __ No
If yes, please describe:

 

45

13. Have you had a graded exercise test (stress test)?
_ Yes __ No If yes, when and where was your most

recent stress test done?

 

Has your doctor instructed you to restrict any
activities? If yes, please describe:

 

 

W:

14. What do you consider as your ideal weight?
What do you consider as realistic short- and long-term
weight loss goals? Short-term (2-3 months)
Long-term (1 year)

15. History of weight problems in your family: Any person
over-weight in you immediate family? (mother, father,
spouse) Explain:

 

16. Who do you live with?
Who usually prepares the food?

 

 

17. Has your doctor directed you to limit your intake of any foods or additives? _
YES _ NO If yes,
what?

 

18. List foods you can not tolerate?

 

 

19. Typical weekly eating pattern - check how often and
where meals/snacks are eaten.

Cany meal Restaurant, Never eat
Home from home Cafeteria this meal
(times/wk) (times/wk) (times/wk) (times/wk)

Morning
Midday

Evening

20. Do you drink alcoholic beverages? _ YES _ NO
If yes, how many ounces do you average per week:
02. Liquor 02. Wine oz. Beer

46

21. Are there any things that you do or that you eat that
you believe may be contributing to your cholesterol
problem? (i.e., overeating at night, never exercising,
etc.)

W:

I understand that my lab results will sometimes be discussed with me by telephone. I can
be reached best at?

Home # Hours

 

Work # Hours

If I am unavailable, I authorize the nurse to discuss these results with

Q

(Name) (Relationship)

I understand that my enrollment in the Promed Lipid Modification Program includes my
authorization for the release of information regarding my progress to my primary provider
or other medical providers (i.e., cardiologist).

 

(Signature) (date)

Cardiologist Information:

 

 

 

 

Name of MD.

Address

City State Zip
Phone FAX

 

 

Adapted from and used with permission from L. Cofer, 1996

APPENDIX C

47

82 5.8 .4 52.. Banana. 5.3 82. ea Ba€<

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.22m E8 on...
£83m humrmr new
868$ .EOm om<
8.22m .88 a?
323m E ”wk.
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3: 2a: _uriaeé. 43 £88 dd .3
I llqu: Ilw .96 .200 baa: :Eaml <>ol n>ml Sal zEl A V96 .Eofil “2:582
m j z a c5 iv 2.2... .8

a .n
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Ema—3.50 8342 3.8
528... .25 2509... 2926:502 48$ E 83.8
32.5; .a 9.5 n89: 3 9592 82.

u 5.9.3.?

APPENDIX D

48

APPENDIX D

SAMPLE: MEDICATION INSTRUCTION

PROMED LIPID MODIFICATION PROGRAM
M l' I' I E l'

NAME: Colestid Tablets (Colestipol)
BUREQSE: To lower total cholesterol and the “bad” or “lousy” LDL.

W: Binding bile acids made up largely of cholesterol) in the intestine which are
then excreted in the stool. As the liver makes more bile acid to replace what is lost, it
utilizes cholesterol fi'om the blood (Bile acids aid in digestion).

DOSE: 2 to 16 tablets per day once or in divided doses.

W: You have severe constipation, triglycerides
greater than 250 or complete biliary obstruction.

W: CALL YOUR DOCTOR OR THE CHOLESTEROL
CLINIC IF YOU HAVE: Constipation, stomach pain, gas, nausea, vomiting, heartburn,
diarrhea, bleeding tendencies, black-tarry stools, irritation of the skin, tongue and perianal
area, backache, headache, and weight loss or gain.

W518: Your cholesterol and triglycerides will be checked
frequently during the first months of therapy and periodically thereafter. A CBC

(complete blood count) and PT (clotting time) will be done annually.

W: Colestid may bind with other medications, decreasing
effectiveness. Take other drugs at least 1 hour before or 4-6 hours after Colestid.

W8: Colestid tablets should be taken whole. Do not chew or
crush tablets.

Adapted and used with pemrission L. Cofer, 1996; Ziajka, I995

APPENDIX E

49

APPENDIX E

SAMPLE: PATIENT LETTER

PROMED LIPID MODIFICATION PROGRAM
7901 Angling Road
Portage, MI 49024
(616) 324-8600

Edward Millermaier, MD
Medical Director - Lipid Program

Mary Ella) Yealin. MSN, FNP
Clinical Director - Lipid Program

Joyce Ross
Registered Dietitian

Date:

 

Dear:

 

We have been unable to reach you by telephone regarding your cholesterol situation.
Please call one of the Lipid Clinic nurses to discuss your results, progress and
recommendation at this time.

Thank you for your cooperation!

Sincerely,

Edward Millermaier, MD
Medical Director

Mary Ellen Yealin, MSN, FNP
Clinical Director

Adapted and used with permission L. Cofer, 1996

APPENDIX F

50

APPENDIX F

SAMPLE: MEMO

 

 

 

Memo From:

PROMED LIPID MODIFICATION PROGRAM
Date:
To:
Your patient, 9 is enrolled in the Promed Lipid Modification
Program . We have added to the medical regime in order to improve

 

lipid levels and decrease cardiovascular risks. We will monitor the response to this
therapy and keep you informed of your patient’s progress. We will contact you
immediately should any problems develop.

Sincerely,

Mary Ellen Yealin, MSN, FNP

Edward Millermaier, MD

LIST OF REFERENCES

51

LIST OF REFERENCES

Berger, A. M., Eilers, J. G., Pattrin, L., Rolf-Fixtoy, M., Pfiefer, B. A., Rogge. J.
A., Wheeler, L. M., Bergstrom, N. I. & Heck, C. S. (1996). Advanced practice roles for

nurses in tomorrow’s health care system. W6), 250-255.

Braunwald, E. (Ed). (1997). Heartdrseaserextbookficardrm/ascular
medicine Philadelphia: W. B. Saunders.

Brown. A. S. (1996. October). Ihuhelesteroleonnectien. Tutorial presented

at a conference in Oakbrook, IL.

Bulachek, G. & McCloskey J. (1992). Lifestyle alteration. In G Bulachek & J.
McCloskey(Eds.). Minimalism; (p. 275-278). Philadelphia: W.B. Saunders.

Cassidy, C. A (1997) Facilitating behavior change. WM
Qccupaflmralflealthflutsiugiifi), 239- 246.

Champion, V. (1994). Beliefs about breast cancer and mammography by
behavioral stage. W6), [009-1014.

Cofer. L. (1996, October). Ihecholestemlmnnectien. Tutorial presented ata

conference in Oakbrook, IL.

Conn, V. S. (1994). A stage-based approach to helping people change health
behaviors. Clinicalflurflpeflalmw), 187-193.

Davidson, M H. (1996). Efficacy of the National Cholesterol Education Program
Step I diet: A randomized trial incorporating quick- -service foods. Amhimmfintemal
Medicine.

Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol
in Adults (Adults Treatment Panel II). (1993, September) Secondiepofiflflhenafional
cholestemledueatmnpmgrammm (NIH Publication No 93-3095)

Fawcett, J. (1989). Conceptual models ngnursing. Philadelphia: F. A. Davis.

52

F enton M V. & Brykczynski, K A. (1993) Qualitative distinctions and
similarities m the practice of clinical nurse specialists and nurse practitioners. loumaLQf

RmfessionaLNursiugfitm, 313-326

Fitzgerald, S. M. & Wood, S. H. (1997) Advanced practice nursing: Back to the
future Iournalefflsmecolegicalandfleonatalflursinufifl), 101- 107.

Gifi, A. G. (1994). Understanding costs. ClinieaLNurseSpecialisLQM), 90.

Goeppinger, J. (1996). Renaissance of primary care: An opportunity for nursing.

In J. Hickey, R. Ouimette, S. Venegoni (Eds) Admnecflraflrceflursmg (p. 63-73).
Philadelphia: Lippincott.

Grundy, S. M. (1997). Cholesterol and coronary heart disease: The 2lst century.
ArehivesoflntemaLMedicineJflW), 157-161.

Harris, M. & Warren, J. (1995). Patient outcomes: Assessment issues for the

CNS. Cliru'eaLNurseSpecialisLfl 2), 82-85.

Hecht, J P., Emmons, K. E, Brown, R A., Everett, K. D, Farrell, N C,
Hitchcock, P., Sales, S D (1994) Smoking interventions for patients with cancer.

Guidelines for nursing practice. QnedogxflumngfiommZLflO) I657- I665.

Hixon, M. E. (1996). Professional development: Socialization in advanced
practice nursing. In J. Hickey, R. Ouimette, S. Venegoni (Eds) Adyancedflactice

Nursingwp. 33-53). Philadelphia: Lippincott.

Jones, K. (1993). Outcome analysis: Methods and issues. NursingEchQmici
11(3), 145-152.

King. I. (1981). W New York:
Wiley.

King, K., Parrinello, K. & Baggs, J. (1996). Collaboration and advanced practice

nursing. In J. Hickey, R. Ouimette, S. Venegoni (Eds) Adxancedflacticehlutsing (PP-
146-162). Philadelphia: Lipincott.

Levins, S. & Ornstein, P. (1990). Management of hypercholesterolemia in a family

practice setting. loumaLQfLEamillflamieeallm) 613-617.

Naylor, M. D.; Munro, B. H.. & Brooten, D. A. (1991). Measuring the
effectiveness of nursing practice. WM), 210-214.

Nugent, K. E. & Lambert, V. A. (1997). Evaluating the performance of an
advanced practice nurse. WW9), 29-32.

53

O Flynn, A. I (I996). The preparation of advanced practice nurses: Current

issues. WW6). 429-437.

Prochaska, J. DiClemente C. & Norcross, J (1992). In search of how people
change AmericanBsmhologLstJQ), 1104- 1114.

Redman, B. K. & Thomas, S. A. (1992). Patient teaching. In G. Bulachek & J.
McCloskey (Eds), Nursinglmememigns (PP. 304-314). Philadelphia: W. B. Saunders.

Rudd, C. L. (1994). Cholesterol intervention in the workplace. American
AssociatienoLQecupationaLNursesAlO), 113- 116.

Safiiet, B. J. (1992). Health care dollars and regulatory sense. Ihelaleloumal
QLReguIatiQaflQ), 417-488.

Satinsky, M. (1996). Advance practice nurse in a managed care environment. In

J. Hickey, R. Ouimette, S. Venegoni (Eds) Adxaneedfltaflleehlutsing (pp. 126-144).
Philadelphia: Lipincott.

Scheffler, S., Waitzman, N, Hillman, 1., (I996). The productivity of physician
assistants and nurse practitioners and health work force policy in the era of managed care.

Journal Qt Allied Health 21(3), 207-217.

Venegoni, S. ( 1996). Changing environment of health care. In J. Hickey, R.

Ouimette, S. Venegoni (Eds) WW (PP- 77'90)~ Philadelphia:
Lipincott.

Ziajka, PE. (1995). Establrshmgandmanagmgapnxatepracneehprdflrme.
New York: Mosby-Wolfe.

APPENDIX A

41

Appendix A
Nomogram for Determining Body Mass Index ( Bray, 1978)

 

 

 

 

 

 

 

 

 

 

WEIGHT HEIGHT
K ‘
KG LU ,, CM IN
. ”DUI «-
tsu- M :31; :[
Ho- INDEX '25:
. ----—-—-- -—so
: . ~ 2' :
"”:,-.z.u l_Wl/(Ill) J _.
:_ r30_
.29.: . .35.,” _-
IIU': 3.240 Sgt-60 '35:?-
DJ‘; :-
90-3 5? -
= Vur III It It _"..
'5‘; ____Y__.l_l___ :24” Very ”I“ .45.!
00-: man .5 m r. :-
: 1 trio--
75: r: '
; Mudurrllu . Moderate :-ao
7°.- -—— - - ~30 ..
5 ‘3 ”5-:-
55; Inw . LOW :b
5 Anna rltllrlr: Acct: )lnblc :
55-. -—-....-L. .- . _. . -2U ' 065:...‘3
50-: '- Ho (70—1
45-51-400 ”5-.
- :- 95 -—70
‘0;:‘ 90 .0021-
.2- 00 "”3"
35-5 ' ' '0 :-
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' :- 10 5’ -
.: ”5:1.
”:5— cs 5..
.:_ 200:.
. f 60 =,_.o
-; 205:.
25- 7 as :_
. 2'0 ..
- so as

 

APPENDIX B

42

Appendix B
Sample Cardiac Focused History

PROMED LIPID MODIFICATION PROGRAM
7901 Angling Road
Portage, MI 49024
(616) 324-8600

Enrollment Questionnaire

 

 

 

 

 

 

 

 

 

 

 

NAME: DATE:
SS#: DATE OF BIRTH:
OCCUPATION:
MEDICAL HISTORY:
1. Do you take any medication on a regular basis?
_ YES _ NO WWW
supplements.
Medication Qosefmg) Ezequeney StarLDate
l.
2.
3.
4.
5.
6.
2. Have you ever taken medication to improve your cholesterol level?
_ YES __ NO

If yes, which one(s)?

 

3. Do you have any allergies? __ YES _ NO
If yes, please list them with type of reaction:

 

 

4. Please indicate whether or not you have or have had any
of the following conditions:

High Cholesterol _ YES _ NO
High Triglycerides _ YES _ NO

43

High Blood Pressure (Hypertension) _ YES _ NO
Coronary Artery Disease __ YES _ NO
Heart Attack Date _ YES _ NO
Bypass Surgery Date _ YES _ NO
Angioplasty Date _ YES _ NO
Atherectomy Date __ YES __ NO
Peripheral Vascular Disease _ YES _ NO
Stroke _ YES _ NO
Aneurysm (bulging arterial wall) _ YES _ NO
Diabetes _ YES _ NO
Thyroid disease or problem _ YES __ NO
Kidney disease __ YES _ NO
Liver disease or jaundice _ YES _ NO
Gall Bladder Disease _ YES _ NO
Gout _ YES _ NO
Peptic Ulcer _ YES __ NO
Intestinal problems (colitis, etc.) _ YES _ NO
Glaucoma _ YES _ NO

5. Women, have you had a hysterectomy? __ YES _ NO
Are you post-menopausal _ YES _ NO
Do you take any hormone supplement? __ YES __ NO

RISK FACTOR ASSESSMENT:

6. Are you a smoker? EX _ YES _ NO

If yes or ex: How much do (or did) yous—moke per day?

How long have (or had) you been smoking?
How long ago did you quit smoking?

7. Has your father had any of the following conditions?

Stroke (est. age __) _YES _NO _Not sure
Heart Attack (est. age _) _YES __NO _Not sure
Bypass surgery (est. age _) _YES _NO _Not sure
Angioplasty (est. age __) _YES _NO _Not sure
Leg pain when walking

(Int. Claud.) _YES _NO _Not sure
Coronary Artery Disease _YES _NO _Not sure
High Cholesterol __YES _NO _Not sure
High Triglycerides _YES _NO _Not sure

8. Has your mother had any of the following conditions?
Stroke (est. age _) _YES __NO _Not sure

10.

ll.

12.

Heart Attack (est. age __) _YES _NO _Not sure
Bypass surgery (est. age __) _YES _NO _Not sure
Angioplasty (est. age _) _YES _NO _Not sure
Leg pain when walking

(Int. Claud.) _YES __NO _Not sure
Coronary Artery Disease _YES _NO _Not sure
High Cholesterol _YES _NO _Not sure
High Triglycerides _YES __NO _Not sure
Has your hrmheLoLsister had any of the following
conditions?
Stroke (est. age _) _YES _NO _Not sure
Heart Attack (est. age _) _YES _NO _Not sure
Bypass surgery (est. age __) _YES _NO _Not sure
Angioplasty (est. age _) _YES _NO _Not sure
Leg pain when walking

(Int. Claud.) _YES _NO _Not sure
Coronary Artery Disease _YES _NO _Not sure
High Cholesterol _YES _NO _Not sure
High Triglycerides _YES _NO __Not sure

Since problematic cholesterol levels are often
inherited, please complete the following:

NamemoflehildfrenlAgeCholesterollestDone

YES _NO _Not sure

 

YES _NO _Not sure

 

YES _NO _Not sure

 

YES _NO _Not sure

 

Describe the type and amount of exercise you do
regularly:

Do you have any pain when walking? __ Yes _ No
If yes, please describe:

 

45

13. Have you had a graded exercise test (stress test)?
Yes No If yes, when and where was your most

recent stress test done?

 

Has your doctor instructed you to restrict any
activities? If yes, please describe:

 

 

WIS:

14. What do you consider as your ideal weight?
What do you consider as realistic short- and long-term
weight loss goals? Short-term (2-3 months)
Long-term (1 year)

15. History of weight problems in your family: Any person
over-weight in you immediate family? (mother, father,
spouse) Explain:

 

16. Who do you live with?
Who usually prepares the food?

 

 

17. Has your doctor directed you to limit your intake of any foods or additives? __
YES _ NO If yes,
what?

 

18. List foods you can not tolerate?

 

 

19. Typical weekly eating pattern - check how often and
where meals/snacks are eaten.

Carry meal Restaurant, Never eat
Home from home Cafeteria this meal
(times/wk) (times/wk) (times/wk) (times/wk)

Morning
Midday

Evening

20. Do you drink alcoholic beverages? _ YES _ NO
If yes, how many ounces do you average per week:
02. Liquor 02. “fine oz. Beer

46

21. Are there any things that you do or that you eat that
you believe may be contributing to your cholesterol
problem? (i.e., overeating at night, never exercising,
etc.)

BELEASEDEINEQRMAIIQN:

I understand that my lab results will sometimes be discussed with me by telephone. I can
be reached best at?

Home # Hours
Work # Hours

If I am unavailable, I authorize the nurse to discuss these results with

9

(Name) (Relationship)

I understand that my enrollment in the Promed Lipid Modification Program includes my
authorization for the release of information regarding my progress to my primary provider
or other medical providers (i.e., cardiologist).

 

(Signature) (date)

Cardiologist Information:

 

 

 

 

Name of MD.

Address

City State Zip
Phone FAX

 

 

Adapted from and used with permission fi'om L. Cofer, I996

APPENDIX C

47

8... 5.6 ... 52. 8.3.5.2. 5.3 .8: 2.. Ban?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.29... .58 &<
8.29.... .58 8..
8.23m :8 a...
3.23. .88 MM
8.29.... E8 8..
8.5 8:55.... “.80 8...... =80. ..==<. .28 :58 02.5 on: .5: 5.. .5: ...:u. 2.5
8.2 as... .5822: .5. 8.38 dd 8..
- .

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m j Z :0 Q5. .5 2.2... 8m

.8 .n
.n .n 9.233
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8322.50 8842 GS.
528:. .25 25.09... 20:57.50: 48.... .2 855..
828... ... 5...... 820.... .3. «5.92 .8“

o 4.22.3

APPENDIX D

48

APPENDIX D

SAMPLE: MEDICATION INSTRUCTION

PROMED LIPID MODIFICATION PROGRAM
II I' I' I a l'

NAME: Colestid Tablets (Colestipol)
RUREQSE: To lower total cholesterol and the “bad” or “lousy“ LDL.

W: Binding bile acids made up largely of cholesterol) in the intestine which are
then excreted in the stool. As the liver makes more bile acid to replace what is lost, it
utilizes cholesterol from the blood (Bile acids aid in digestion).

QQSE: 2 to 16 tablets per day once or in divided doses.

W: You have severe constipation, triglycerides
greater than 250 or complete biliary obstmction.

W: CALL YOUR DOCTOR OR THE CHOLESTEROL
CLINIC IF YOU HAVE: Constipation, stomach pain, gas, nausea, vomiting, heartburn,
diarrhea, bleeding tendencies, black-tany stools, irritation of the skin, tongue and perianal
area, backache, headache, and weight loss or gain.

W: Your cholesterol and triglycerides will be checked
frequently during the first months of therapy and periodically thereafter. A CBC

(complete blood count) and PT (clotting time) will be done annually.

W: Colestid may bind with other medications, decreasing
effectiveness. Take other drugs at least l hour before or 4-6 hours after Colestid.

W: Colestid tablets should be taken whole. Do not chew or
crush tablets.

Adapted and used with permission L. Cofer, 1996; Ziajka, 1995

APPENDIX E

49

APPENDIX E

SAMPLE: PATIENT LETTER

PROMED LIPID MODIFICATION PROGRAM
7901 Angling Road
Portage, MI 49024
(616) 324-8600

Eduard Millermaier. MD
Medical Director - Lipid Program

Mary Ellen Yealin. MSN, FNP
Clinical Director - Lipid Program

Joyce Ross
Registered Dietitian

Date:

 

Dear:

 

We have been unable to reach you by telephone regarding your cholesterol situation.
Please call one of the Lipid Clinic nurses to discuss your results, progress and
recommendation at this time.

Thank you for your cooperation!

Sincerely,

Edward Millermaier, MD
Medical Director

Mary Ellen Yealin, MSN, FNP
Clinical Director

Adapted and used with permission L. Cofer, 1996

APPENDIX F

50

APPENDIX F

SAMPLE: MEMO

 

 

 

Memo From:

PROMED LIPID MODIFICATION PROGRAM
Date:
To:
Your patient, , is enrolled in the Promed Lipid Modification
Program . We have added to the medical regime in order to improve

 

lipid levels and decrease cardiovascular risks. We will monitor the response to this
therapy and keep you informed of your patient’s progress. We will contact you
immediately should any problems develop.

Sincerely,

Mary Ellen Yealin, MSN, FNP

Edward Millermaier, MD

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