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 |
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Elements define the essential outcomes |
Performance criteria describe the performance needed to demonstrate achievement of the element. |
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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. |
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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. |
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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. |
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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.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705