Physical Assessment The systems to include: Skin: general pigmentation.turgor.etc Abdominal: + bowel sound all 4 quads; address if they are hypo/...

Physical Assessment

The systems to include:

Skin: general pigmentation…turgor..etc

Abdominal: + bowel sound all 4 quads; address if they are hypo/ hyper

Cardiac

Peripheral  vascular:

Respiratory: Normal indication: resp rate [insert #] even unlabored no use of accessory muscles

Must include:

PQRSTU 1 minimum for 1 system on the list

3 pertinent negatives example: for normal breath sounds: no adventitious breath sounds. DO NOT USE N/A or just negative; Use medical terminology (refer to Jarvis text)

Don’t forget recommendations (Client education for Positive findings) and summary

PT refusal: use the word “deferred”; Pt refused PV exam due to recent back surgery”