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Unit of competency details

HLTENN004 - Implement, monitor and evaluate nursing care plans (Release 1)

Summary

Usage recommendation:
Superseded
Mapping:
MappingNotesDate
Supersedes HLTEN504C - Implement and evaluate a plan of nursing careThis 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
Is superseded by and equivalent to HLTENN038 - Implement, monitor and evaluate nursing careThis version was released in HLT Health Training Package Release 6.0 and meets the requirements of the 2015 Standards for Training Packages. Mapping information updated. Updated to reflect current industry practices and terminology. 29/Apr/2021

Releases:
ReleaseRelease date
1 1 (this release) 08/Dec/2015


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 1

This 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.

Supersedes HLTEN504C

Application

This unit describes the skills and knowledge required to implement nursing care as outlined in a person’s plan of care, evaluate outcomes of care provided, record and report progress, and respond to an emergency situation.

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. Prepare a person for care procedures.

1.1 Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

1.2 Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

2. Implement care procedures to meet identified needs.

2.1 Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

2.2 Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

2.3 Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

2.4 Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

2.5 Use appropriate measures to promote the person’s comfort, rest and sleep.

2.6 Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

2.7 Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

2.8 Use emergency codes correctly and initiate basic life support according to organisation policy and procedures.

3. Monitor a person’s identified care needs.

3.1 Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

3.2 Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

3.3 Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

4. Evaluate outcomes of care provided.

4.1 Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

4.2 Evaluate the person’s progress towards planned outcomes as documented in the care plan.

4.3 Make required changes to nursing care plan in line with best practice in nursing.

4.4 Record and report all aspects of the evaluation of nursing care provided.

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

 

Assessment requirements

Modification History

Release 

Comments 

Release 1

This 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.

Supersedes HLTEN504C

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 work in in accordance with Nursing and Midwifery Board of Australia professional standards of practice, codes and guidelines
  • implemented and monitored at least 2 different nursing care plans in the workplace
  • evaluated at least 1 nursing care plan in the workplace or in a simulated environment
  • used emergency codes and performed basic life support in a simulated environment on an adult, child and infant manikin according to organisation policy and procedures.

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:

  • activities of daily living
  • factors that promote and impede comfort, sleep and rest
  • purpose of hygiene and grooming
  • actual and potential nursing care including:
  • hygiene and toileting
  • elimination needs, including procedures used to assist with elimination
  • incontinence management, including aids or devices
  • physical comfort
  • sleep disturbances
  • oral hygiene including:
  • teeth brushing
  • care of dentures
  • using alcohol-free mouthwash
  • interdental cleaning
  • immobility
  • respiration and circulation
  • fluid and nutritional deficits
  • pain
  • underlying medical condition
  • sensory deficits, including use of personal aids and devices
  • cognitive deficits
  • basic life support including:
  • how to perform cardiopulmonary resuscitation (CPR)
  • use of and response to emergency codes
  • considerations when providing basic life support including
  • airway obstruction due to body position
  • appropriate duration and cessation of CPR
  • appropriate use of an Automatic External Defibrillator (AED)
  • risk identification related to episodic care:
  • age
  • anaesthesia and surgery
  • cognitive status
  • deep vein thrombosis, venous thromboembolism, pulmonary embolism
  • immobility
  • length of stay
  • mental health condition
  • non-compliance
  • nutritional status
  • pain
  • presence of morbidity
  • risk prevention strategies including:
  • maintaining a safe environment
  • preventing falls and falls assessment
  • promoting active and passive exercises
  • promoting deep breathing and coughing exercises
  • maintaining skin integrity and pressure area care
  • recording and reporting requirements for comprehensive clinical handovers and case meetings.

Assessment Conditions

Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. The requirement of the performance evidence to implement and monitor at least 2 different nursing care plans in the workplace must have been demonstrated in simulation before being demonstrated in the workplace and with members of the public. The following conditions must be met for this unit:

  • use of suitable facilities, equipment and resources in line with the Australian Nursing and Midwifery Accreditation Council’s Standards, including:
  • simulation manikins for adult, child and infant suitable for demonstration of life support skills
  • defibrillator or AED
  • lifting equipment used to manage risks involved in moving and positioning a person
  • equipment used in deep breathing and coughing exercises
  • equipment used in active and passive exercises
  • risk prevention documentation, nursing care plans and progress notes used in the planning of nursing care
  • 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.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705