______________________________                _________________

Patient                                                                         Chart number

Check appropriate option below, sign and date

Complete Physician Actions

Complete and sign BP Titration Protocol Flow Sheet

___   Hydrochlorothiazide (HCTZ)    

Diabetics treated with HCTZ have an average increase in fasting glucose of 5 mg/dL.

Preferred first line agent

Avoid if GFR <30

• Write prescription: HCTZ 12.5mg    One daily # 30
• Write lab prescription: BMP Q week  RF X 3 months  Dx Hypertension
• Instruct patient to Check BMP after taking HCTZ for 2 to 3 weeks
• Schedule Nurse BP visit 4 weeks after starting  HCTZ
  • Notify clinician if BP not at goal
  • If not at goal, avoid increasing above 12.5mg HCTZ; add another agent

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Physician signature                                                        Date

___    ACE inhibitor: captopril [Capoten], enalapril [Vasotec], lisinopril [Zestril], quinapril [Accupril], ramipril [Altace], or

___    ARB losartan [Cozaar], candesartan [Atacand], olmesartan [Benicar], valsartan [Diovan], irbesartan [Avapro], telmisartan [Micardis], eprosartan [Teveten])

Physician actions for ACE/ARB

• Write prescription ACE/ARB  Take as directed  #60 RF x3
• Write prescription BMP Q week X 6 months  Dx: Hypertension
• Record target dose for ACE/ARB above  (e.g., Lisinopril 20mg/day)
• Calculate and record creatinine level 30% above baseline

• RN instructs patient to start ACE/ARB per dose recommendations below
• RN instructs patient to Check BMP after taking ACE/ARB for 1 week
• RN schedules Nurse BP visit after patient takes new dose of ACE/ARB for 2 weeks
  • If BP or medication dosage not at goal, and BMP within parameters:
    • Nurse increases dose per recommendations below
    • Nurse instructs patient to get BMP one week after new dose
    • Nurse instructs patient for nurse BP visit two weeks after new dose

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Physician signature                                                        Date

___    Beta blocker (BB)

• Preferred 3^rd agent if history of CAD, MI, CABG, angioplasty
• Avoid BB if severe, uncontrolled bronchospastic illness (asthma, COPD)
• β1 selective BBs (atenolol, metoprolol) are safe if used with caution in patients with asthma, COPD,  peripheral vascular disease
  • COPD patients treated with BB show decreased risk of CV death
• Partial β agonist BB (labetalol) may slow heart rate less  
• BB can reduce GFR

Physician actions for BB

• Record BP goal
• Record Dosage goal

Nursing actions for BB

• Nurse BP visit every 2 weeks X 6 as needed
• Nurse checks BP and heart rate
• Nurse monitors for possible BB Adverse Effects
  • Adverse effects: shortness of breath, edema, fatigue, insomnia, cold extremities
• Notify physician if HR <60, possible adverse effects, or patient reaches BP goal
  • If BP or medication dose not at goal, and HR >60, and no adverse effects, then:
  • RN instructs patient to increase dose per recommendations below

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Physician signature                                                        Date

Calcium Channel Blocker

___    Long-acting non-dihydropyridine channel blocker (CCB) (e.g., verapamil, diltiazem)

Contraindications:

• AV node dysfunction with second or third degree AV block
• Heart failure
• Severely decreased LV function

___    Long acting dihydropyridine CCB

(e.g. amlodipine, felodipine, isradipine, nicardipine, nifedipine, nisoldipine)

Physician actions for CCB

• Record BP goal
• Record dosage goal

Nursing actions for CCB

• Nurse BP visit every 2 weeks X 6 as needed
• Nurse checks BP and heart rate
• Nurse monitors for CCB adverse effects
  • Adverse effects: Shortness of breath, edema, fatigue, slow heart rate, heart block, constipation, nausea, headache
• Nurse notifies physician if HR <60, possible adverse effects, or patient reaches BP goal
  • If BP not at goal, HR >60, and no adverse effects:
  • RN instructs patient to increase dose per recommendations below

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Physician signature                                                        Date