Individual Pulmonary Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of exacerbation: Allergies: Physician: Office vs:

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1 Individual Pulmonary Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of exacerbation: Allergies: Physician: Office vs: (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #1 Exercise Exercise Exercise Exercise 6-MWT Stress test Other: 6-MWT Stress test Other: walked ft max HR O2 walked ft max HR O2 RPE SPO2 MET level RPE SPO2 MET level Exercise prescription THR Exercise prescription Exercise prescription Exercise prescription Mode TM B STP EG EL R Mode TM B STP EG EL R Mode TM B STP EG EL R Mode TM B STP EG EL R Frequency Frequency Frequency Frequency Duration Duration Duration Duration Intensity Intensity Intensity Intensity Progression Progression Progression Progression SPO2 O2 Y N Liters SPO2 O2 Y N Liters SPO2 O2 Y N Liters SPO2 O2 Y N Liters Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Resistance train Y N Wt# Reps Hypertension Y N Medication Diet Hypertension Y N /Medication Diet Resting Peak Exercise BP Current BP: Current BP: Resting Peak Exercise HR Meds: Med change: Y N Med change: Y N Med change: Y N Home exercise: Home exercise: Home exercise: Home exercise: Type Frequency Type Frequency Type Frequency Type Frequency Duration O2 at LPM Duration O2 at LPM Duration O2 at LPM Duration O2 at LPM Resistance training: Y N Resistance training: Y N Resistance training: Y N Resistance training: Y N PLB RPE scale PLB RPE scale PLB RPE scale Education goals met: Y N Ex safety Dyspnea scale Ex safety Dyspnea scale Ex safety Dyspnea scale S/S to report Wm-up/cl-dn S/S to report Wm-up/cl-dn S/S to report Wm-up/cl-dn Diap breathing Equip orient Diap breathing Equip orient Diap breathing Equip orient O2 therapy Energy conser O2 therapy Energy conser O2 therapy Energy conser SPO2 > during exercise SPO2 > during exercise SPO2 > during exercise SPO2 > during exercise Individual exercise Rx (1) Individual exercise Rx (1) Individual exercise Rx (1) Individual exercise Rx (1)

2 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #2 Nutrition Nutrition Nutrition Nutrition Diabetes: Y N FBS HbA1c Diabetes: NA FBS HbA1c Diabetes: NA FBS HbA1c Diabetes: NA FBS HbA1c Diabetes medication: Med change: Y N Random BS Med change: Y N Random BS Med change: Y N Random BS Monitor BS at home Y N freq BS in range Y N BS in range Y N BS in range Y N Weight management: WT HT Weight management: Weight management: Weight management: WT HT % fat Waist cir BMI Current WT Current WT % fat Waist cir BMI Wt goal: Wt goal: Wt goal: Wt goal: Special diet Vitamins/supplements Alcohol daily weekly special none type amount Diet assess tool Diet assess tool score score Dietician consult: Y N Dietician consult: Y N Dietician consult: Y N Dietician consult: Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Nurse/patient discussion Y N Dietary goal: Dietary goal: Dietary goal: Dietary goal: Diet class Y N Diet class Y N Diet class Y N Diet class Y N Referral to Diabetes education Y N Referral to Diabetes education Y N Referral to wt management program Y N Referral to wt management program Y N S/S hypo/hyper glycemia S/S hypo/hyper glycemia S/S hypo/hyper glycemia Education goals met: Y N Relate DM to pul disease Relate DM to pul disease Relate DM to pul disease Eating Healthy Eating Healthy Eating Healthy HbA1c <7% HbA1c <7% HbA1c <7% HbA1c <7% BMI <25 Waist cir <40in M/<35in F BMI <25 Waist cir <40in M/<35in F BMI <25 Waist cir <40in M/<35in F BMI <25 Waist cir <40in M/<35in F

3 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #3 Education Education Education Education Learning barriers: speech hearing vision literacy cognitive ready learn Family support Y N Family support Y N Family support Y N Family support Y N Knowledge test score: Knowledge test score: Tobacco use: Y N Tobacco use: Y N Tobacco use: Y N Tobacco use: Y N quit < 6 mo >6 mo Date started date quit Date quit Date quit Date quit Quit date set Quit date set Quit date set Quit date set # cigarettes smoked per day # cigarettes smoked per day # cigarettes smoked per day # cigarettes smoked per day Smokeless tobacco Y N amt Smokeless tobacco Y N amt Smokeless tobacco Y N amt Smokeless tobacco Y N amt PFT Y N PFT Y N ABG'S Y N ABG'S Y N Breath sounds Breath sounds Breath sounds Breath sounds Chest physio flutter acapella vest Chest physio flutter acapella vest Chest physio flutter acapella vest Chest physio flutter acapella vest Referral to cessation class Y N Referral to cessation class Y N Referral to cessation class Y N Referral to cessation class Y N Individual education and counseling Y N Individual education and counseling Y N Individual education and counseling Y N Individual education and counseling Y N Tobacco adjunct Y N Tobacco adjunct Y N Tobacco adjunct Y N Tobacco adjunct Y N Education class schedule given Y N Attended Ed classes Y N Attended Ed classes Y N Attended Ed classes Y N Tobacco triggers Tobacco triggers Tobacco triggers Dyspnea man Pulmonary A&P Dyspnea man Pulmonary A&P Dyspnea man Pulmonary A&P Risk factors Lung gas exchg Risk factors Lung gas exchg Risk factors Lung gas exchg Education goals met: Y N Med compliance Sexuality Med compliance Sexuality Med compliance Sexuality Prevent infect Negulizer Use Prevent infect Negulizer Use Prevent infect Negulizer Use Traveling Bronchodilaters Traveling Bronchodilaters Traveling Bronchodilaters Inspiratory Muscle Training Bronchial hygiene Inspiratory Muscle Training Bronchial hygiene Inspiratory Muscle Training Bronchial hygiene Control cough ADL's Control cough ADL's Control cough ADL's Enviro triggers Aerochanger Enviro triggers Aerochanger Enviro triggers Aerochanger Co-morbidities: Co-morbidities: Co-morbidities: Complete cessation of tobacco use Complete cessation of tobacco use Complete cessation of tobacco use Complete cessation of tobacco use Self-man and prevention/tx exacerbation (1) Self-man and prevention/tx exacerbation (1) Self-man and prevention/tx exacerbation (1) Self-man and prevention/tx exacerbation (1) Restore to highest level of independ funct (1) Restore to highest level of independ funct (1) Restore to highest level of independ funct (1) Restore to highest level of independ funct (1)

4 (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) (Circle all BOLD that apply) PG #4 Psychosocial Psychosocial test: Psychosocial test: Tool used: Tool used: Score Score Psych Consult: Y N Psych Consult: Y N Psych Consult: Y N PsychConsult: Y N Physician referral Y N Physician referral Y N Physician referral Y N Physician referral Y N Psychotropic medication: Med change: Y N Med change: Y N Med change: Y N Stress management class: Y N Stress management class: Y N Stress management class: Y N Stress management class: Y N Uses stress management skills: Y N Uses stress management skills: Y N Uses stress management skills: Y N Uses stress management skills: Y N Coping techniques Coping techniques Coping techniques Education goals met: Y N S/S depression S/S depression S/S depression Breaking dyspnea cycle Breaking dyspnea cycle Breaking dyspnea cycle Support system Support system Support system Relaxation techniques Relaxation techniques Relaxation techniques Assess presence or absence Assess presence or absence Assess presence or absence Assess presence or absence of depression using a valid screening tool of depression using a valid screening tool of depression using a valid screening tool of depression using a valid screening tool Maximize coping skills (2) Maximize coping skills(2) Maximize coping skills (2) Maximize coping skills (2) Positive support system (2) Positive support system (2) Positive support system (2) Positive support system (2) Patient/program goal: Patient/program goal: Patient/program goal: Patient/program goal: Fall risk assess Y N Assistive device C W Wh/ch GB Session number: Session number: Session number: Session number: No changes, proceed with rehab Please add/change the following: Physician signature/date: Physician signature/date: Physician signature/date: Physician signature/date:

5 References AACVPR : Guidelines for Pulmonary Rehabilitation Programs, 3rd ed.. Champaign, IL: Human Kinetics, ACSM Guidelines for Graded Exercise Testing and Prescription, ed. 8. Baltimore, MD: Lipppincott Williams and Wilkins, ACSM Resource Manual for Guidelines for Exercise Testing and Prescription, ed. 5., Baltimore, MD: Lippincott Williams and Wilkins, ) Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals: American Association of Cardiovascular and Pulmonary Rehabilitation Position Statement Nici L et al. Journal of Cardiopulmonary Rehabilitation and Prevention 2007;27: ) ACCP/AACVPR Evidence-Based Guidelines for Pulmonary Rehabilitation Ries AL. Editorial in Journal of Cardiopulmonary Rehabilitation and Prevention 2007;27: Full article in Chest 2007;131;4-42 Key 6MWT=6 minute walk test Max=maximum Wh/ch=wheel chair HR=heart rate ft=feet O2=oxygen RPE=rate of perceived exertion meds=medication Maint=maintain PLB=pursed lip breathing orient=orientation BP=blood pressure RPE=rate of perceived exertion Diap=diapramatic wm-up=warm up ex=exercise Prep=preparation BS=blood sugar cl-dn=cool down s/s= signs and symptoms TM=treadmill freq=frequency act=activity Rx=prescription B=bike cir=circumference DM=diabetes mellatis ed=education STP= stepper BMI=basic metabolic index MET=metabolic equivalent A&P=anatomy and physiology EG=ergo meter wt=weight vs=visit psych=psychological EL=ellipiltical Ther=therapy equip=equipment FBS=fasting blood sugar R=rower m=male man=management Pul=pulmonary PFT=pulmonary function test f=female #=number Amt=amount ABG=arterial blood gas physio=physiology infect=infection ADL=activity of daily living Exchg=exchange Enviro=enviromental tx=treatment Y=yes N=no C=cane W=walker GB=gait belt Ht=height DOB=date of birth

Individual Cardiac Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of event: Allergies:

Individual Cardiac Treatment Plan rev 1/10 Name: DOB: Age: Date entered program: Diagnosis: Date of event: Allergies: Risk strat for cardiac event: Physician: Office vs: low moderate high (Circle all BOLD