Unit of competency details

HLTENN003 - Perform clinical assessment and contribute to planning nursing care (Release 2)

Summary

Usage recommendation:
Current
Mapping:
MappingNotesDate
Supersedes HLTEN503B - Contribute to client assessment and developing nursing care plansThis version was released in HLT Health Training Package release 3.0 and meets the requirements of the 2012 Standards for Training Packages. Significant changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency requirements. Minimal change to knowledge evidence. 07/Dec/2015

Release Status:
Current
Releases:
ReleaseRelease date
2 (this release) 19/Sep/2018
(View details for release 1) 08/Dec/2015


Training packages that include this unit

Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 060307 Community Nursing  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 060307 Community Nursing  29/Apr/2016 
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Unit Of competency

Modification History

Release 

Comments 

Release 2

This version was released in HLT Health Training Package release 4.1.

Updated Knowledge Evidence to remove references to resources which are now obsolete.

Release 1

This version was released in HLT Health Training Packagerelease 3.0 and meets the requirements of the 2012 Standards for Training Packages.

Significant changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency requirements. Minimal change to knowledge evidence.

Supersedes HLTEN503B

Application

This unit of competency describes the skills and knowledge required, within the scope of practice, to perform preliminary and ongoing physical health assessments of all body systems, gathering data that contributes to a person’s individualised health care plan.

This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.

The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.

Elements and Performance Criteria

ELEMENT 

PERFORMANCE CRITERIA 

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Collect and interpret health data.

1.1 Introduce self and explain processes before commencing nursing assessment activities.

1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

1.7 Clarify the emotional and physical needs of the family or carer in supporting the person.

1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

1.9 Communicate immediately all deterioration concerns about the person to registered nurse.

2. Undertake admission and discharge procedures for a person.

2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

2.3 Identify community support services and resources to assist in planning for discharge.

2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

3. Contribute to planning the nursing care of a person.

3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs.

3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

4. Contribute to ongoing development of individual nursing care plans.

4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

4.3 Ensure nursing care plan is based on principles of best practice and risk assessment.

4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.

Foundation Skills

The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance.

Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.

Unit Mapping Information

No equivalent unit.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705

 

Assessment requirements

Modification History

Release 

Comments 

Release 2

This version was released in HLT Health Training Package release 4.1.

Updated Knowledge Evidence to remove references to resources which are now obsolete.

Release 1

This version was released in HLT Health Training Packagerelease 3.0 and meets the requirements of the 2012 Standards for Training Packages.

Significant changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency requirements. Minimal change to knowledge evidence.

Supersedes HLTEN503B

Performance Evidence

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

  • undertaken nursing work in accordance with Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines
  • performed nursing admission and discharge procedures for 2 different people in the workplace as per organisation policy and procedures
  • conducted holistic clinical health assessment on 2 different people in the workplace or in a simulated environment including:
  • blood glucose monitoring
  • oxygen saturation level
  • body mass index (BMI) or waist hip ratio
  • integumentary assessment
  • urinalysis
  • neurological observations including reflexes
  • neurovascular observations and assessment of peripheral circulation
  • pain assessment (including chest pain)
  • developed at least 1 nursing care plan in the workplace or in a simulated environment based on holistic health assessment undertaken with a real person.

Knowledge Evidence

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

  • admission and discharge planning processes and documentation required
  • developmental stages of childhood:
  • physical growth and psychosocial, cognitive and motor development of the toddler and the pre-school and school aged child
  • physical growth and cognitive and motor development of infants 0-12 months
  • role of play in a child’s development
  • impact of hospitalisation on child and family
  • developmental stages of adolescence and common health issues for adolescents
  • developmental stages of adulthood and major activities related to each stage
  • impact of infertility on people
  • approaches to understanding human growth and development
  • influences of genetics and environment on development
  • family health care needs
  • gender-specific health care needs
  • how to use equipment for health assessment and data collection
  • how to assist a person in activities of daily living including identified aids to assist these activities
  • how to perform clinical measurements and/or assessments for:
  • blood glucose level
  • blood pressure
  • body mass index or waist hip ratio
  • height and weight
  • level of consciousness
  • pupil reaction
  • neurological reflexes
  • peripheral circulation
  • sensory perception and identified personal aids and devices required for hearing or sight
  • skin colour, integrity and turgor
  • temperature, pulse, respirations
  • urinalysis
  • human growth and development
  • interpretation and analysis of a person’s health-related information
  • principles of health assessment
  • problem solving strategies and techniques for conducting health assessment
  • how to recognise a deteriorating patient and determine levels of consciousness
  • how and when to raise issues of concern about a person’s deterioration
  • wellness approach to health, including physiology and psychosocial aspects
  • variations in health needs and activities of daily living across the person’s lifespan.

Assessment Conditions

Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. The following conditions must be met for this unit:

  • using suitable facilities, equipment and resources in line with the Australian Nursing and Midwifery Accreditation Council’s Standards including:
  • appropriate biomedical equipment to undertake measurement or monitoring of vital signs and BMI
  • neurological assessment tools
  • urinalysis test strips
  • oximeter
  • blood glucose monitoring device and test strips
  • scenario based nursing care plans, charts and progress notes used for simulation
  • data collection instruments
  • organisation policy and procedures on which the candidate bases the planning process
  • modelling of industry operating conditions including access to real people for simulations and scenarios in enrolled nursing work.

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

In addition, assessors must hold current registration as a registered nurse with Nursing and Midwifery Board of Australia.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705