MAHSA UNIVERSITY
CARDIORESPIRATORY ASSESSMENT FORM &
GUIDELINES
Content Remarks
Demographic Data:
Name
Age
Sex
R/N
Date of Assessment
Date of Admission (if in patient)
Doctor’s Diagnosis
Doctor’s Management
Subjective Assessment:
1. Main When it started
problem/ Do you cough?
chief Do you have sputum – how
complain much, what colour, can it
come out
2. Current Hx When admitted
Why admitted
Current medical/ surgical tx
Why refer for physio
3. Past Hx Relating to current problem
Any previous admission to
hospital
Any previous surgery
4. Social Hx Home situation: living with
who/carer/ home environment
Occupation/ recreation
Smoking/alcohol: How many
perday?
5. Special General Health
Question Past medical hx
Medication
Surgical hx
Investigations : CXR, ABG
Objective Assessment
1. Vital Sign Temperature
RR
HR
B/P
SPO₂
2. ABG PH
PcO₂
PO₂
HCO₃
BE
SaO₂
3. Observation General: Built, nourishment
Local:
1. Skin colour
2. Chest wall shape/deformity
3. Clubbing
4. Breathing pattern, level
5. Coughing: Productive/non-
productive
6. Sputum:
Colour/amount/consistency
7. O₂ tx: type?
8. Posture
9. Cyanosis
10. Chest drain
4. Palpation Chest expansion (thumb
placement)
Chest measurement
(Measuring tape)
Percussion note
Auscultation
5. Muscle #UL & LL (general)
power
6. Functional Bed mobility (if
ability applicable)
Sit at the edge of couch
Sit-to-stand
Standing balance
Ambulation
7. Special test 6-minutes walk test
(exs tolerance)
Incentive spirometer
Analysis : What cause the
1) Problem list prob?
2) Short term goal Prioritize the
problem
3) Long term goal
Plan of treatment Related to the
problem
Intervention Patient’s position
Intensity of
treatment
Evaluation Evaluation after the
tx
Using outcome
measure to see the
effectiveness
Post vital sign
Review What to review for
the next visit
Assessment?
Treatment?
