Physical Assessment Requirements for Continuing Care Clinical

The purpose of monitoring nursing students physical assessment during Continuing Care
Clinical is to ascertain whether the student can complete a physical assessment that will ensure
that they have basic knowledge. The purpose of this assessment is not to determine whether
the student can complete a physical assessment as per HEAS 1000.

The student should complete the following assessment on each assigned resident prior
to breakfast each day or as instructed by the Clinical Instructor:

1. Vital Signs
 Blood Pressure
 Radial Pulse - describe
 Respirations – describe
2. CNS
 Pain Assessment – PQRSTU
 Level of Consciousness
 Orientation
 Communication barriers
3. Cardiovascular
 Apical Pulse – describe
4. Respiratory
 Lung sounds including presence or absence of adventitious sounds
 Air entry – bilaterally increased, decreased, equal
 If on oxygen, check lines and connections from wall or oxygen concentrator/stroller to
patient
5. Gastrointestinal
 Bowel sounds – normal, hyperactive, hypoactive
 Abdomen observation – rounded, flat, distended
 Palpation – firm, soft
6. Genitourinary
 Voiding – continent, incontinent
 Mode of voiding – bathroom, incontinent pad, commode
 Catheter – urine character, amount
7. Integumentary
 CTEMPS
 Edema – pitting, non-pitting, mild, moderate, gross
 Description of skin integrity on bony prominences including the presence or absence
of any new changes to skin integrity

Developed June 16, 2014; Revised June 30, 2014

The student should complete the additional assessment on each assigned resident prior
to Post Conference:

1. Mouth
 Mucous membranes – colour, moisture
 Teeth - dentition, dentures
2. Sensory
 Hearing
 Vision
3. Musculoskeletal
 Muscle strength – hand grips, leg movement, bilateral, character of strength – strong,
moderate, weak
 Capillary refill
 Active or passive range of motion
4. Gastrointestinal
• Nausea
• Vomiting
• Bowel movement – formed, diarrhea, continent, incontinent, colour

The student should complete the resident’s Temperature and Oxygen Saturation as
indicated below:

1. Temperature – every Tuesday and Friday unless febrile

2. Oxygen Saturation – every Tuesday and Friday unless on oxygen
3. Glasgow Coma Scale – as required based on the needs of the resident
4. Braden Scale – as required based on the needs of the resident

Developed June 16, 2014; Revised June 30, 2014