Diabetes Planned Visit Notebook

2.13 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: ________________

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 ________

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: __________________

Date Medication Current dose SBP DBP Apical Lab Date Na K Cr Adverse Effects Dose change Initials
                    see back    
                         
                         
                         
___ 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
                    see back    
                         
                         
                         
___ Continue current plan
___ Discontinue protocol                                               Physician/NP signature: ________________________________________________

Have you experienced any new or worsening:

___ = YES  If Yes, describe below___ = NO

Date                    
Weakness                    
Swelling                    
Wheezing                    
Cough                    
Shortness of breath                    
Constipation                    
Nausea                    
Fatigue                    
Palpitations                    
Insomnia                    
Nightmares                    
Coolness of hands/feet                    
Headache                    
Dizziness                    
Rash                    
Initials                    

Describe:

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Page last reviewed October 2014
Internet Citation: 2.13 Blood Pressure Titration Protocol Flow Sheet. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk213.html