PATIENT CARE PLAN: Pulmonary Rehabilitation
Admitting Diagnosis:
EXERCISE: See MD orders.
Exercise workloads will be progressed gradually within limits of patient’s ability.
Progression based on Borg dyspnea of 3-5 and absence of untoward symptoms during exercise.
INDIVIDUAL COUNSELING: Education on disease self management strategies including:
 Dyspnea control techniques at rest, activity and ADLs  Inhaled and respiratory medications
 Exacerbation prevention & management  O2 Rx, system, safety  ADL management and pacing
 Panic & depression management  Nutrition & weight management  Smoking cessation
 Home exercise plan & guidelines  Intimacy  Safe travel  Advanced directives
Name: _________________________ Date: _____________
 history of pneumonia  hospitalized for resp. exacerbation
 CHF  HTN Cardiac other: ________________________
 Ortho _______________________  Osteoporosis______
 Neurological______________________________________
 GERD GI
disorder:_________________________________
 Diabetes  glucometer  Rx _______________________
 Depression  Anxiety  Rx_______________  counselor
 OSA  CPAP / BiPAP  Insomnia  Rx_______________

 Improve
Surgeries_________________________________________
S
Clinical Note:
R

PATIENT GOALS
 Breathe better
 Take medications correctly
 Increase endurance/stamina
 Symptom management _________________
 Improve weight
 Stop smoking / maintain cessation
 Control panic / anxiety
 Return to recreation/hobby/work _______________
Other: ______________________________________________________________
Problems /
Goals
Education by RN or
RCP __ sessions
Problem:
Knowledge deficit
self management
 Ineffective
control of dyspnea
Goal:
Effectively
partners with MD /
team to prevent and
manage diseaserelated impairments
Hypoxemia
Problem:
 Hypoxemia
 No home O2
 No port. O2
 Needs O2 Rx
recommendation
poor knowledge
O2 use/safety
Goal
 Hypoxemia
managed
 Port system
 Using O2 as
Rx’d / safely
Initial Assessment
Session # 1
Plan
Date/Initial :
___________
 Knowledge
deficit of disease
self management
strategies
 Poor control of
dyspnea
Barriers to learning:
speech 
hearing vision
literacy
cognitive
______________
 ready to learn
Education topics: training by
RN or RCP
 Disease overview
 Breathing strategies,
dyspnea control at rest, with
panic, exercise, ADLS
 Respiratory medication
 Exacerbation prevention,
management
 Panic control
 Secretion clearance
 travel intimacy
 Home exercise program
 Advance directives
Initial SpO2: _____
 Monitor SpO2 at rest and
with exercise
 Recommend appropriate
FiO2 to patient and physician
 Assist pt to contact DME for
home O2  portable O2
 Train in appropriate use of
O2 at rest and with exercise
 Train in O2 safety
 Train in O2 systems
FiO2____________
Port O2_________
Stationary O2
_______________
DME___________
____________________________________
____________________________________
Reassessment
Reassessment
Final Assessment
Session # _________
Session # __________
Session # __________
Date/Initials: _______
Date/Initial: ____________
Date/Initial: _______________
Demonstrates disease
self-management strategies
 Dyspnea control during
rest, ADLs and exercise
Using Rxs as directed
Mobilizes secretions
effectively
Demonstrates strategies
for anxiety and depression
management
Demonstrates knowledge
of O2 Rx at rest and with
exercise
Demonstrates knowledge
of O2 safety
Using O2 as Rx’d
Has home O2 as Rx’d
Uses port. O2 as Rx’d
Demonstrates disease selfmanagement strategies
 Dyspnea control at rest /
with activity
Using Rxs as directed
Mobilizes secretions
effectively
Demonstrates strategies for
anxiety and depression
management
Demonstrates knowledge of
O2 Rx at rest and with
exercise
Demonstrates knowledge of
O2 safety
Using O2 as Rx’d
Has home O2 as Rx’d
Uses port. O2 as Rx’d
Demonstrates disease
self-management strategies
 Dyspnea control at rest /
with activity
Using Rxs as directed
Mobilizes secretions
effectively
Demonstrates strategies
for anxiety and depression
management
Demonstrates knowledge
of O2 Rx at rest and with
exercise
Demonstrates knowledge
of O2 safety
Using O2 as Rx’d
Has home O2 as Rx’d
Uses port. O2 as Rx’d
PATIENT CARE PLAN: Pulmonary Rehabilitation
Admitting Diagnosis:
EXERCISE: See MD orders.
Exercise workloads will be progressed gradually within limits of patient’s ability.
Progression based on Borg dyspnea of 3-5 and absence of untoward symptoms during exercise.
INDIVIDUAL COUNSELING: Education on disease self management strategies including:
 Dyspnea control techniques at rest, activity and ADLs  Inhaled and respiratory medications
 Exacerbation prevention & management  O2 Rx, system, safety  ADL management and pacing
 Panic & depression management  Nutrition & weight management  Smoking cessation
 Home exercise plan & guidelines  Intimacy  Safe travel  Advanced directives
Name: _________________________ Date: _____________
 history of pneumonia  hospitalized for resp. exacerbation
 CHF  HTN Cardiac other: ________________________
 Ortho _______________________  Osteoporosis______
 Neurological______________________________________
 GERD GI
disorder:_________________________________
 Diabetes  glucometer  Rx _______________________
 Depression  Anxiety  Rx_______________  counselor
 OSA  CPAP / BiPAP  Insomnia  Rx_______________

 Improve
Surgeries_________________________________________
S
Clinical Note:
R

PATIENT GOALS
 Breathe better
 Take medications correctly
 Increase endurance/stamina
 Symptom management _________________
 Improve weight
 Stop smoking / maintain cessation
 Control panic / anxiety
 Return to recreation/hobby/work _______________
Other: ______________________________________________________________
Problems /
Goals
Initial Assessment
Session # 1
Plan
Date/Initial :
___________
____________________________________
____________________________________
Reassessment
Reassessment
Final Assessment
Session # _________
Session # __________
Session # __________
Date/Initials: _______
Date/Initial: ____________
Date/Initial: _______________
Reassessment
Problems /
Goals
Psychosocial
Assess/Management: Problem:
 Depression
 Anxiety
 Panic
 Ineffective
coping
Impaired quality
of life (QOL)
Goal:
 Improved
psychosocial
coping strategies
 Verbalizes
coping mechanisms
Initial Assessment
Session # 1
Date/Initial : ___________
Depression:
 self report
 depression screening
test __________________
score:________________
 Anger  Anxiety
 Stress  Panic
 Impaired QOL
QOL score ___________
_____________________
Medications____________
_____________________
 Referred for MD
counseling
Plan
Session # _________
Date/Initials: _______
Instruction:
 Review screening results
 Benefits of exercise
 Relaxation techniques
 Stress management &
Relaxation
□ On meds currently
□ Receiving counseling
□ Recommend counseling
□ Recommended follow-up with
MD for consideration of Rx
Reassessment
Session # __________
 Management of stress and
depression
 Practicing Interventions
 Counseling referral
 Demonstrates coping
strategies
Final Assessment
Session # __________
Date/Initial:
___________________
 Management of stress and
depression
 Practicing Interventions
Date/Initial:
___________________
 Management of stress and
depression
 Practicing Interventions








Met
Progressing
Not progressing
_____________
Met
Progressing
Not progressing
_____________
 Counseling referral
 Counseling referral
 Management of ADLs with
control of dyspnea
 Following OT
recommendations
 Has ordered assistive
devices
 Management of ADLs with
control of dyspnea
 Following OT
recommendations
 Has ordered assistive
devices
Appropriate stair
climbing
Appropriate stair climbing
 Management of ADLs with
control of dyspnea
 Following OT
recommendations
 Has ordered assistive
devices
 Met
 Progressing
 Not progressing
_____________
 Train in coping strategies
 Adequate
treatment of
depression
Improved QOL
Activities of
Daily Living
Problems: 
Impaired ADL
management
Goal: ADL
management with
control of dyspnea
Nutrition &
Weight
Management
Problem:
□ Overweight
□ Cachexia
Goal:
 BMI 21 to 25
 Wt loss 1-2 lb
per week
 prevent further
weight loss
 Waist
Circumference
< 35 in female
< 40 in male
Impaired ADL
management
 Fear +/or severe
dyspnea with stairs
 Need for OT eval
 Need for assistive
devices
Instruction:
 ADL performance with pacing,
dyspnea control
 OT evaluation
 Assistive device evaluation
recommendations and resources
Knowledge deficit
management of
□ overweight:
□ Cachexia
□ Osteoporosis
□ lack of Vit D / Ca++ sup
Poor understanding of:
□ role of exercise in weight
management
□ wt control with
Prednisone
□ RD consult
□ Review BMI or WC and identify
target weight and strategies for
weight management
□ Education class (nutrition
strategies, role of supplements,
Prednisone and weight control
strategies)
□ Education re: need for ongoing
weight monitoring
□ Food diary
□ Physical activity log
Weight: ___________
BMI: ______________
WC: ______________
Admit Weight _________
Admit Ht _____________
Admit BMI _____________
Admit WC_____________
 Train in dyspnea control /
pacing with stairs
 Met
 Progressing
 Not progressing
_____________
 Met
 Progressing
 Not progressing
_____________
 BMI 21 to 25
 wt loss 1-2 lb/ week
 weight stable
 WC < 35 female
WC < 40 male
 BMI 21 to 25
 wt loss 1-2 lb/ week
 weight stable
 WC < 35 female
WC < 40 male
 BMI 21 to 25
 wt loss 1-2 lb/ week
 weight stable
 WC < 35 female
WC < 40 male
Weight: ___________
BMI: ______________
WC: ______________
 Goal met
 Progressing
 Not progressing
 Referral to structured
weight management program
_______________
Weight: ___________
BMI: ______________
WC: ______________
 Goal met
 Progressing
 Not progressing
 Referral to structured
weight management program
_______________
Weight: ___________
BMI: ______________
WC: ______________
 Goal met
 Progressing
 Not progressing
 Referral to structured weight
management program
_______________
PATIENT CARE PLAN: Pulmonary Rehabilitation
Problems /
Goals
Initial Assessment
Session # 1
Date/Initial :
___________
Reassessment
30 days/Date: ______
Plan
Date/Initials: _______
Medications
Problem:
□ Medication
Non-adherence
Goal:
□ Adherence to
prescribed medications
□ Patient reports taking
medications as
prescribed __________
% of the time.
□ Review prescribed
medications’ purpose,
side-effect and
importance of
compliance
Inhaled medications
Problem:
□ Incorrect inhaled Rx
use, technique
Goal:
□ Correct
technique/timing &
care MDI, DPI,
nebulizer
Pt demo correct
technique:
MDI: □ Yes □ No □ NA
DPI: □ Yes □ No □ NA
Neb: □ Yes □ No □ NA
□ When to replace MDI
□ Yes □ No □ NA
___________________
Instruct correct
technique/timing & care:
□ MDI
□ DPI
□ Nebulizer
□ Return demo use of
MDI
Secretion clearance
Problem:
□ Ineffective secretion
clearance
Goal:
□ pt demonstrates
effective cough,
effective secretion
clearance
Problem: Knowledge
deficit:
 Respiratory
Infection Prevention /
Management
Goal:
□ pt describes
signs/symptoms of
infection, methods to
identify and prevent
Pt reports:
 No cough
 Non-prod cough
 Prod cough w/
infections
 Prod cough daily <1
Tbsp.
 Prod cough daily > 1
Tbsp.
Nasal congestion
Pt reports:
 Rare respiratory
infection
 0-1/yr respiratory
infection
 >1/yr respiratory
infection
 Hospitalized in past
12 mo x ___
Inadequate cleaning of
respiratory equipment
Session # _________
Instruct:
 Controlled cough
 CPT
 Vibratory PEP device
 VEST
 Role of exercise in
secretion clearance
 NS nasal spray
 _________________
Instruct:
 Hydration
 Hand hygiene
 Evaluate sputum
 When to call MD
 s/sx to report :
purulent sputum, >
dyspnea, > fatigue
 influenza vaccine
pneumovax
□ cleaning of respiratory
equipment
 Medication list reviewed
Taking medications 100% of
the time
 Met
 Approx ______%
 Not progressing
 ______________
Pt demo correct
technique/timing:
MDI: Yes □ No
□ Reinstructed
DPI: □ Yes □ No
□ Reinstructed
Neb: □ Yes □ No
□ Reinstructed
Pt demo correct:
Effective cough: □ Yes □ No
□ Reinstructed
CPT: □ Yes □ No
□ Reinstructed
Device: □ Yes □ No
□ Reinstructed
 NS nasal spray
Sputum management:
□ Improved □ No Change
□ ___________________
Pt demo:
Improved hydration: □ Yes □
No □ Reinstructed
Hand washing: □ Yes □ No
□ Reinstructed
Eval sputum: □ Yes □ No
□ Reinstructed
Verbalize when to call MD:
□ Yes □ No
□ Reinstructed
□ cleaning of respiratory
equipment
Reassessment
60 days/Date:
_______________
Session # __________
Date/Initial:
___________________
 Medication list reviewed
Taking medications 100% of the
time
 Met
 Approx ______%
 Not progressing
 ______________
Final Assessment
90 Days/Date:
_________________
Session # __________
Date/Initial:
___________________
 Medication list reviewed
□ Taking medications 100% of
the time
 Met
 Approx ______%
 Not progressing, see DC
Summary
 ______________
Pt demo correct
technique/timing:
MDI: □ Yes □ No □
Reinstructed
DPI: □ Yes □ No □
Reinstructed
Neb: □ Yes □ No □
Reinstructed
Pt demo correct
technique/timing:
MDI: □ Yes □ No □ See DC
Summary
DPI: □ Yes □ No □ see DC
summary
Neb: □ Yes □ No □ See DC
Summary
Pt demo correct:
Effective cough: □ Yes □ No
□ Reinstructed
CPT: □ Yes □ No
□ Reinstructed
Device: □ Yes □ No
□ Reinstructed
 NS nasal spray
Sputum management:
□ Improved □ No Change
□ ___________________
Pt demo:
Improved hydration: □ Yes
□ No □ Reinstructed
Hand washing: □ Yes □ No
□ Reinstructed
Eval sputum: □ Yes □ No
□ Reinstructed
Verbalize when to call MD:
□ Yes □ No
□ Reinstructed
□ cleaning of respiratory
equipment
Pt demo correct:
Effective cough: □ Yes □ No
□ Reinstructed
CPT: □ Yes □ No
□ Reinstructed
Device: □ Yes □ No
□ Reinstructed
 NS nasal spray
Sputum management:
□ Improved □ No Change
□ ___________________
Pt demo:
Improved hydration: □ Yes □ No
□ See DC Summary
Hand washing: □ Yes □ No
□ See DC Summary
Eval sputum: □ Yes □ No
□ See DC Summary
Verbalize when to call MD: □ Yes
□ No
□ See DC Summary
Reassessment
Problems /
Goals
Exercise & Fitness
Problem:
□ Deconditioning
□ No regular exercise
□ Knowledge deficit
exercise guidelines
and safety
Goal:
□ Aerobic Exercise
30-60 mins x 9 weeks
□ PR: 2-3/wk
□ Resistance: 2-3
times weekly
□ _____________
Diabetes
Management
Problem:
□ non-fasting BG □<
80
□>240
□ Poor knowledge of
DM management
Goal:
□ non-fasting BG 80240
□ HbA1C <7%
□ self-mngt of DM
Initial Assessment
Session # 1
Date/Initial : ___________
Plan
Date/Initials: _______
Current Exercise level:
Type: ______________
Frequency: _________
Duration: ___________
□ Sedentary or
< 3x/week for 20 mins
□ barriers to exercise
____________________
Initial MET Level ______
THR: _______________
Diabetic: □ Yes □ No
Type: ____________
 BG (blood glucose)
levels:____________
□ Self Monitors BG at
home:
□ Yes □ No
Frequency:__________
□ HbA1C < 7
□ HbA1C ___________
Session # _________
□ Review with patient
benefits and core
components of exercise
program
□ Review how to palpate
and monitor dyspnea
level
□ Review exercise
intensity
□ Review exercise safety
guidelines
□ Review home exercise
guidelines
Aerobic Exercise
30-60 mins 3-7x/wk
THR: ___________
 Met
 Progressing
 Not progressing
 _____________
MET Level _________
Time: ______ minutes
□ obtain glucometer
□ schedule DM program
□ non-fasting BG 80-240
□ Review
signs/symptoms of
hyper/hypoglycemia
 N/A
□ non-fasting BG 80-240
□ HbA1C <7%
HbA1C _________
 Met
 Progressing
 Not progressing______
Home Exercise:
Mode: ____________
Freq: ______ times/wk
Time: ______ minutes
□ RD consult/coaching
appt
Stamper Plate:
---------------------------------------------------------
Final Assessment
Session # __________
Date/Initial:
___________________
Date/Initial:
___________________
Aerobic Exercise
30-60 mins 3-7x/wk
THR:____________
 Met
 Progressing
 Not progressing
 _____________
MET Level ___________
Time: _________ minutes
Aerobic Exercise
30-60 mins 3-7x/wk
THR:____________
 Met
 Progressing
 Further f/u –see DC summary
 ______________
MET Level ___________
Time: ________ minutes
Home Exercise:
Mode: ____________________
Freq: _______ times/wk
Time: ________ minutes
Home Exercise:
Mode: ______________
Freq: _______ times/wk
Time: ________ minutes
 N/A
□ non-fasting BG 80-240
□ HbA1C <7%
HbA1C _________
 Met
 Progressing
 Not progressing
 _______________
 N/A
□ non-fasting BG 80-240
□ HbA1C <7%
□HbA1C __________
 Met
 Progressing
 Further f/u –see DC summary
 ____________
□ Patient to take BG pre
&/or post exercise.
Staff Signatures/credentials:
________________________
________________________
________________________
Reassessment
Session # __________
Medical Director:
MD Initial Review
 Outcome assessment reviewed
 Exercise plan approved as documented
 Exercise plan approved with the following
modifications:
 Treatment plan and goals support patient
needs/ abilities
 Special precautions concerning this patient:
MD f/u Review
 Continue with current program
 Continue program with the
following changes:
MD Review
 Continue with current program
 Continue program with the
following changes:
MD Signature ________________
MD Signature ________________
Date ___________Time________
Date _____________Time ______
Final Review
 Outcome Assessment Reviewed
MD Signature ______________________
MD Signature ____________________________ Date ______________
Date _____________________Time________