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: __________________

DateMedicationCurrent doseSBPDBPApicalLab DateNaKCrAdverse EffectsDose changeInitials
          see back  
             
             
             
___ Continue current plan
___ Discontinue protocol                                              Physician/NP signature: ________________________________________________
DateMedicationCurrent doseSBPDBPApicalLab DateNaKCrAdverse EffectsDose changeInitials
          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 January 2008
Internet Citation: 2.13 Blood Pressure Titration Protocol Flow Sheet. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/diabnotebk/diabnotebk213.html