Nursing

Complete Physical Assessment on a patient. USE BULLET FORMAT

· 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

· Neuro

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

Also, example; PT refusal: use the word “deferred”; Pt refused peripheral vascular disease exam due to recent back surgery”