Rt Consult Form Side #1

Respiratorytherapycave.blogspot.com RESPIRATORY THERAPY CONSULT FORM ( ) Initial Assessment/ Evaluation

Patient Label

( ) Re-Assessment/ Evaluation

INDICATORS FOR AEROSOL THERAPY: (check all that apply) ( ) Bronchospasm/ wheezing ( ) Asthma/ reactive airway disease ( ) Diminished lung sounds ( ) COPD ( ) Prolonged expiratory phase ( ) Obstructive defects of PFT ( ) Impaired mucous clearance ( ) History of Pulmonary disease INDICATORS FOR HYPERINFLATION THERAPY: ( ) Prolonged bed rest ( ) Diminished Lung Sounds ( ) Atelectasis ( ) Abdominal/Thoracic surgery ( ) Prevent Atelectasis ( ) Restrictive lung defect INDICATORS FOR BRONCHOPULMONARY HYGENE THERAPY: ( ) Productive Cough ( ) History of mucous producing disease ( ) Rhonchi ( ) Pneumonia ( ) Difficulty with secretion clearance with increased sputum production

MDI CRITERIA: 1. Can physically perform the maneuver. 2. Can follow directions. 3. Is cooperative and alert. 4. Can take a slow deep inspiration. 5. Can hold breath for at least five seconds. 6. Is able to perform a return demonstration. 7. Respiratory rate <= 25

PATIENT INFORMATION: A Respiratory Therapist has evaluated this patient. Based on the patient’s clinical indications, the Respiratory Care Plan designated below will be implemented. Date/Time of Assessment__________________ Ordering Physician _________________________________ Diagnosis_______________________________ Allergies: _________________________________________ Pre-existing pulmonary disease: ______________________________________________________________ Home Respiratory Orders: __________________________________________________________________ BASIC ASSESSMENT AND LABS: HR_____ RR_____ Temp_____ BP_______I&Os_________________ SpO2_____ FiO2/LPM_____ PEFR: pre _____post _____ Pred. PEFR______ PEFR effort_____ Hgb______ Lung sounds_______________________________WOB___________________________________________ ABG: Date/Time_________________ FiO2_____ SaO2_____ Ph_____ PO2_____ PCO2_____ HCO3_____ Smoking history: ( ) Yes ( ) No Cough_____________________ Secretions_________________________ RECOMMENDED CARE PLAN: ( ) Albuterol 0.5cc ( ) Duoneb ( ) Xoponex 1.25mg ( ) Xoponex 0.63mg ( ) Q2& prn ( ) Q4 & prn ( ) QID & prn ( ) Q6prn ( ) Ventolin MDI Q6prn ( ) 2.5mg Atrovent ( ) Q4 ( ) Q8 ( ) QID ( ) Atrovent MDI 2 puffs QID ( ) IS instruct Q1 W/A ( ) CPT QID & prn to tolerance ( ) Combivent MDI 2 puffsQID OTHER RECOMMENDATIONS/ NOTES: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

RRT signature/ Date/ Time__________________________________________________ Physician signature/Date/Time_______________________________________________

RRT Signature/Date/Time________________________________________________________________ Physician signature/Date/Time_____________________________________________________________