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RESPIRATORY THERAPY CONSULT FORM

( ) Initial Assessment/ Evaluation ( ) Re-Assessment/ Evaluation

INDICATORS FOR AEROSOL THERAPY: (check all that apply) MDI CRITERIA:
( ) Bronchospasm/ wheezing ( ) Asthma/ reactive airway 1. Can physically perform
disease the maneuver.
( ) Diminished lung sounds ( ) COPD 2. Can follow directions.
3. Is cooperative and alert.
( ) Prolonged expiratory phase ( ) Obstructive defects of PFT 4. Can take a slow deep
( ) Impaired mucous clearance ( ) History of Pulmonary disease inspiration.
INDICATORS FOR HYPERINFLATION THERAPY: 5. Can hold breath for at
( ) Prolonged bed rest ( ) Diminished Lung Sounds least five seconds.
( ) Atelectasis ( ) Abdominal/Thoracic surgery 6. Is able to perform a
( ) Prevent Atelectasis ( ) Restrictive lung defect return demonstration.
INDICATORS FOR BRONCHOPULMONARY HYGENE THERAPY: 7. Respiratory rate <= 25
( ) Productive Cough ( ) History of mucous producing disease
( ) Rhonchi ( ) Pneumonia
( ) Difficulty with secretion clearance with increased sputum production
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:
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RRT signature/ Date/ Time__________________________________________________

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