2.12 Blood Pressure Titration Protocol for the Diabetes Planned Visit

Diabetes Planned Visit Notebook

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

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

___________________________________________________________________________

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

___________________________________________________________________________

Physician signature__________________________________ Date_________________

___    Beta blocker (BB)

  • Preferred 3rd 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

___________________________________________________________________________

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

___________________________________________________________________________

Physician signature__________________________________ Date_________________

Current as of January 2008
Internet Citation: 2.12 Blood Pressure Titration Protocol for the Diabetes Planned Visit: Diabetes Planned Visit Notebook. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk212.html