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Date/Time:________ Allergies_____________________ Hgt_____ Wt______
Albuterol Inhalation Per Protocol Medications Reminder: Albuterol to be administered per RT Protocol for patients >14
years of age. b
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albuterol 2.5 mg/3 mL (0.083%) inhalation solution Inhalation 2.5 mg 4XDAY
Inh Respiratory Therapy Bronchodilator therapy as per Respiratory Therapy
Protocol b
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albuterol 2.5 mg/3 mL (0.083%) inhalation solution Inhalation 2.5 mg Q2H
PRN Shortness of breath Inh Respiratory Therapy Bronchodilator therapy as
per Respiratory Therapy Protocol c
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albuterol CFC free 90 mcg/inh inhalation aerosol Inhalation 3 inh 4XDAY Inh
Respiratory Therapy ; Bronchodilator therapy as per Respiratory Therapy
Protocol c
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albuterol CFC free 90 mcg/inh inhalation aerosol Inhalation 3 inh Q2H PRN
Shortness of breath Inh Respiratory Therapy ; Bronchodilator therapy as per
Respiratory Therapy Protocol Communication b Respiratory Therapist to discontinue Albuterol Inhalation Per Protocol
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powerplan when patient meets criteria Revision date: 2/19/2013 c Other
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Albuterol Inhalation Per Protocol
Wellspan Health Page 1 of 1 Patient Demographics
c Gettysburg Hospital d
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c York Hospital d
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c WellSpan Surgical and Rehabilitation d
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Hospital Physician Signature___________________________________ Print All