RT Consult Form side #2

GUIDELINES FOR DETERMINING AEROSOL THERAPY & FREQUENCY: Chart Assessment: Points Pulmonary Status

0  No History Smoking

X

1 Smoking History <10 Pack years

Surgical Status

No Surgery

General Surgery

Abdominal Surgery

Thoracic Surgery

Chest X-Ray

Clear or   None

Chronic Radiographic changes

Infiltrates Atelectasis Pleural Effusions

Infiltrates in more than one lobe

Patient Assessment: Points 0 X 1 Dyspnea on Respiratory Regular  Pattern Exertion Pattern

Alert Orientated

Mental Status

Cooperative

Clear to

Breath Sounds

Auscultation

Cough

Strong Spontaneous  NonProductive

Level Activity O2

Ambulatory

No O2

Requirements

Determining Triage #: Assessment Total >20 16-19 11-15 6-10 0-5

Triage # 1 2 3 4 5

Lethergic, Follows Commands

X

2 History of  Pulmonary disease

X 2 Rapid Shallow Breathing >24 Confused, does follow Commands

Decreased LS

Crackles/ Rhonchi

Strong Productive

Weak  Cough, no Rhonchi

Ambulatory W/ Assist 1-2 LPM

 NonAmbulatory 3-6 LPM

X

3 History of  Acute Exacerbation

X 3 Increased Work of  Breathing

Minimal Response to Stimuli Wheezing

Weak  Cough With Rhonchi Paraplegic

>50% <100% Assessment total_________________  Triage #________________________ 

X

4 Severe or  Acute Exacerbation

X Tota Totall

Thoracic w/ Pulmonary Disease Infiltrates with Pulmonary Disease X 4 Severe SOB Use of  Accessory Muscles  Non Responsve

X Total

Audible Wheezing/ Absent  No spontaneous Cough with Rhonchi

Quadraplegic 100%

E. Frequency of Bronchodilator (Based on triage #) Triage # Frequency 1 Q2 & PRN 0.5cc Ventolin and Q4 2.5mg Atrovent 2 Q4 & PRN 0.5cc Ventolin and Q8 0.5mg Atrovent 3 QID & PRN 0.5cc Ventolin and/or 0.5 mg Atrovent 4 Q6 PRN 2.5mg Ventolin or 2 puffs Ventolin MDI if   MDI criteria criteria met or consider consider discontinuing therapy. Also consider 2 puffs Atrovent QID or 2 puffs Combivent QID.