Blood Pressure
Titration Protocol Flow Sheet
Diabetes planned
visits address several health topics of concern to the diabetic patient,
including high blood pressure. This document provides guidance for prescribing
medication to control blood pressure.
Blood Pressure Titration Protocol
Name: _____________________________ Chart#
______________ PCP: _______________________
Date protocol initiated:
______________ Baseline BP: _________/_________
BP goal: ___ <130/70 ___ <125/70 (microalbumin, nephropathy) ___ other ____________________________
Baseline Creatinine _______________
Estimated GFR: ________________
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Physician/NP
Notification Parameters
Systolic BP <_______(100) >_________(180) Serum Na <______(130) >________(147)
Diastolic BP <_______(50) >_________(110) Serum K >5.0 <3.5
Apical pulse <_______(50-60)
>_________(100) Serum creatinine >30% above baseline ________ |
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Physician/NP Orders
Diagnosis: ___ HTN__ DM-uncontrolled
Medication:
______________________________ Dose Initiated: __________________________
Increase dosage according to BP
titration protocol to: Target dose _______ Maximum dose __________
Nurse visit for BP, HR, Review
for Adverse effects Q _________________ BMP Q ____________________
Other:
__________________________________________ Signature: __________________
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Date |
Medication |
Current dose |
SBP |
DBP |
Apical |
Lab Date |
Na |
K |
Cr |
Adverse Effects |
Dose change |
Initials |
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___ Continue
current plan
___ Discontinue
protocol Physician/NP
signature: ________________________________________________ |
Date |
Medication |
Current dose |
SBP |
DBP |
Apical |
Lab Date |
Na |
K |
Cr |
Adverse Effects |
Dose change |
Initials |
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___ Continue
current plan
___ Discontinue
protocol Physician/NP
signature: ________________________________________________ |
| Have you experienced any new
or worsening:
___ = YES If Yes, describe below ___ = NO
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Weakness |
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Swelling |
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Wheezing |
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Constipation |
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Fatigue |
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Palpitations |
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Insomnia |
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Nightmares |
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Coolness of hands/feet |
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Headache |
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Dizziness |
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Rash |
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Initials |
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Describe:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
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540 Gaither Road Rockville, MD 20850 