SURNAME INITIALS & STUDENT NO

Cardiopulmonary I Assessment Form

PATIENT INFO

NAME:

HOSPITAL NO.:

AGE:

DATE OF ADMISSION:

DIAGNOSIS:

OCCUPATION:

PRSESENT HISTORY:

PAST MEDICAL HISTORY:

SOCIO-ECONOMIC HISTORY:

EXECTATION FROM PHYSIO:

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MANAGEMENT

MEDICATION IN HOSPITAL:

DRUG NAME ROUTE DOSAGE EFFECTS SIDE EFFECTS PHYSIO

PRECAUTIONS

INVESTIGATIONS

CHEST XRAY

Date 28/08/2017

Variables Right lung Left lung

Bones:
 Clavicle
 Sternoclavicular
 Ribs

Landmarks:
 Costophrenic
 Cardiophrenic
 Dome of diaphragm

Lung fields:
 Volume
 Air entry
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 Opacities

VITALS

HEART RATE
BLOOD PRESSURE
RESPIRATORY RATE
TEMPERATURE
ANALYSIS

GENERAL OBSERVATION

FACIAL EXPRESSION

POSTURE

EXTERNAL DEVICES AROUND THE PATIENT

INTERCOSTAL DRAINAGE (ICD)

 COLOUR
 LEVEL OF FLUID
 SWING

LOCAL OBSERVATION

CHEST SHAPE:

DYSPOEA:

BREATHING PATTERN:

CYANOSIS:

CAPILLARY REFILL:

CLUBBING:

OEDEMA:

COUGH:
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PHYSICAL OBSERVATION

RESPIRATORY RATE:

HEART RATE/PULSE:

PALPATION:

CHEST EXPANSION

CHEST SYMMETRY

CHEST EXPANSION:

DIFFERENCE ANALYSIS

AXILLA

XIPHOID

10TH INTERCOUSTAL

AUSCULTATION:

R ANTERIOR R POSTERIOR L ANTERIOR L POSTERIOR

APICAL/SUPERIOR

MIDDLE/LINGULAR

LOWER
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PAIN: (Vas scale)

0 10

TRUNK MOBILITY

FORWARD FLEXION

SIDE FLEXION

ROTATIONS

EXTENSION

ARM MOVEMENTS

PEFR

MEASUREMENTS 1
HEIGHT 2
AGE 3
EXPECTED
ANALYSIS OF FINDINGS
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EXERCISE TOLERANCE

BEFORE AFTER AFTER REST

HR HR HR
RR

Maximum heart rate

Target heart rate
ANALYSIS

FUNCTIONAL ABILITIES:

ICF
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TREATMENT PLAN
Long term
Functional Problem Limiting Factors Short term Goal Long Term Goal Precautions Treatment
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WARD PROGRAMME

ACTIVITY FREQUENCY REPETITIONS