HLTENN037 Perform clinical assessment and contribute to planning nursing care

Release: 2

HLTENN037 Perform clinical assessment and contribute to planning nursing care

Modification History

Release	Comments
Release 2	Release 2 HLTENN037 Perform clinical assessment and contribute to planning nursing care supersedes and is equivalent to Release 1 HLTENN037 Perform clinical assessment and contribute to planning nursing care. Updated: Mapping details and minor corrections.
Release 1	HLTENN037 Perform clinical assessment and contribute to planning nursing care supersedes and is equivalent to HLTENN003 Perform clinical assessment and contribute to planning nursing care.

Application

This unit of competency describes the performance outcomes, 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 an individualised health plan of care.

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 (NMBA) regulatory authority legislative requirements.

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

No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.

Pre-requisite Unit

Nil

Competency Field

Enrolled Nursing

Unit Sector

Enrolled Nursing

Elements and Performance Criteria

ELEMENTS	PERFORMANCE CRITERIA
Elements describe the essential outcomes	Performance criteria describe the performance needed to demonstrate achievement of the element.
1. Perform admission assessment.	1.1. Introduce self and explain processes before commencing nursing assessment activities. 1.2. Collect and record admission information including gender, age, cultural, religious and spiritual information in accordance with organisational policies and procedures, and practice standards. 1.3. Perform baseline clinical assessment and document findings including vital signs. 1.4. Interpret and analyse objective and subjective assessment data against normal range. 1.5. Record lifestyle patterns, health history and current health practices. 1.6. Clarify emotional and physical needs of the families and carers. 1.7. Document and communicate alterations and deteriorations of health status.
2. Contribute to plan of nursing care.	2.1. Analyse health history and health assessment to identify risks, likely impacts on daily living activities and care needs. 2.2. Use a problem-solving approach to assist comprehensive nursing care planning. 2.3. Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in nursing care planning and documentation.
3 Evaluate and modify plan of nursing care.	3.1. Analyse, evaluate and review nursing care planning decisions with registered nurse and multidisciplinary health care team. 3.2. Confirm with the person, families or carers that planned nursing care reflects their needs including their uniqueness, culture, religious beliefs and management of stress. 3.3. Ensure plan of nursing care is based on principles of contemporary, evidence-based practice and incorporates risk assessment. 3.4. Review and evaluate plan of nursing care to ensure care needs are met.
4. Perform discharge procedures.	4.1. Collect discharge planning data. 4.2. Contribute to nursing assessment and document issues to facilitate discharge. 4.3. Identify community support services and resources to assist in discharge planning. 4.4. Check to ensure discharge requirements are planned and updated including follow up requirements, discharge prescriptions, My Healthcare Record, referrals and reports for ongoing treatment to health practitioners.

Foundation Skills

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

Unit Mapping Information

HLTENN037 Perform clinical assessment and contribute to planning nursing care supersedes and is equivalent to HLTENN003 Perform clinical assessment and contribute to planning nursing care.

Links

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