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:

__________________________________________________________________________________________________________________

Diabetes Planned Visit Notebook

2.13 Blood Pressure Titration Protocol Flow Sheet

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Blood Pressure Titration Protocol