A nurse is contributing to the plan of care for a client who was admitted to the neurological unit

Descriptor 

This unit of competency describes the skills and knowledge required of an Enrolled/Division 2 Nurse in contributing to the development of individualised health care plans by collection of data captured during a client's preliminary and ongoing health assessments. Assessment is based on a lifespan approach

Application 

The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements

Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurses and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements

Employability Skills 

This unit contains Employability Skills

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element.

ELEMENT 

PERFORMANCE CRITERIA 

1. Collect data that contributes to client health care plan

1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions

1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client

1.3 Perform other clinical measurements/assessments such as activities of daily living

1.4 Record lifestyle patterns and coping mechanisms in documentation

1.5 Document current client health practices, issues and needs

1.6 Document gender, age, cultural, religious and/or spiritual data in preliminary health assessment

1.7 Identify the likely impact of specific health care on the client's health

1.8 Involve client in the process of data collection wherever possible

1.9 Access client information from appropriate family member or carer (if client is unable)

1.10 Identify the emotional and physical needs of family and significant others in supporting the client

1.11 Document and report variations from normal on a regular basis

1.12 Validate extraordinary findings immediately, document and report abnormalities to the registered nurse

1.13 Undertake ongoing client assessment

2. Undertake client assessment for admission and discharge

2.1 Collect client-based data for admission and /or discharge planning

2.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice

2.3 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors

2.4 Follow organisation policies and procedures relating to client participation

2.5 Undertake client admission with understanding of processes involved and key issues to be addressed

2.6 Take into account individual's values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate

2.7 Document client information, such as community resources, to assist in planning for discharge

2.8 Accurately record and report admission and discharge information

3. Analyse client health assessment data and observations

3.1 Accurately interpret information gained from health assessments and observations as being within normal range and/or refer to appropriate health care colleague for interpretation

3.2 Report change in client health status in a timely manner to the appropriate health care colleague

3.3 Identify the likely cause of any significant variation(s) from normal in relation to providing care

3.4 Reflect consideration for age and developmental state of client in performance of clinical nursing assessment

3.5 Analyse physiological aspects of human growth and its impact on client health

3.6 Reflect the client's interests, physical, emotional and psychosocial needs in documentation

3.7 Respect cultural, spiritual and religious wishes during nursing assessment

3.8 Use client health history as part of planning care in line with health organisation requirements

4. Contribute to the development of individual care plans for clients

4.1 Conduct a holistic health assessment reflecting the nursing philosophy or theory of the organisation in consultation/collaboration with a registered nurse

4.2 Use appropriate health assessment tools and appropriate terminology in documentation as well as a variety of sources and clinical situations

4.3 Use a problem solving approach in the development of care plans for clients

4.4 Discuss care requirements with the client and/or their family or significant other to ensure information is accurate

4.5 Verify client based information to ensure client's uniqueness and individuality is reflected in the care plan

4.6 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse

4.7 Record age and gender issues in the development of individualised care plans

4.8 Incorporate cultural, spiritual and religious beliefs in the development of individualised care plans

4.9 Ensure documentation reflect the client's needs: physical, emotional, spiritual and psychosocial

4.10 Ensure nursing care plan addresses principles of best practice and risk assessment and identifies stress management techniques for clients

5. Prepare for client discharge

5.1 Identify appropriate community support services to the client

5.2 Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice

5.3 Ensure client has all requirements for discharge: next GP's appointment; medications; and any referrals

5.4 Ensure documentation is completed as per policy and procedure

REQUIRED SKILLS AND KNOWLEDGE 

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge :

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

• Admission and discharge planning
• Confidentiality and privacy
• Effects of biological maturation and ageing processes on body systems and their components
• Equipment for use in nursing skills or data collection
• Human growth and development:

• age specific health care needs
• cultural, religious and spiritual beliefs and practices related to health status
• developmental stages of childhood:

• growth, psychosocial development and the cognitive and motor development of the toddler, pre-school and school aged child
• physical growth, cognitive and motor development of infants 0-12 months
• role of play in a child's development
• the impact of hospitalisation for the child and family

• developmental stages and major issues of adolescence
• developmental stages of adulthood, major activities related to each stage of adulthood and impact of infertility
• different approaches to understanding human growth and development
• differing influences of genetics and environment on development
• family health care needs
• gender specific health care needs
• variations in activities of daily living across the lifespan

• Health needs across the lifespan
• In-depth understanding of the structure and functioning of anatomy and physiology of the human body and pathophysiology of disease as addressed in unit HLTAP501A Analyse health information 
• Interpretation and analysis of client information
• Legal and professional standards of practice
• Principles of health assessment - problem solving, strategies and techniques for conducting health assessment
• Wellness approach to health - physiology and psychosocial

Essential skills :

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

• Apply documentation principles:

• appropriate terminology
• data collection instruments used in health care environments
• legally compliant recording and reporting
• types of data to be collected in health care environment

• Apply information technology skills
• Apply health care procedures:

• admission and discharge procedures
• assessment of activities of daily living
• assessment of pain
• blood glucose monitoring
• holistic client assessment
• measurements - temperature, pulse, respirations and blood pressure
• neurological observations
• neurovascular observations
• observations
• oximetry, body mass index
• physical assessment
• specimen collection
• urinalysis

• Apply professional standards of practice:

• ANMC code of conduct
• ANMC code of ethics
• ANMC national Enrolled/Division 2 nurse competency standards
• state/territory Nurse Regulatory Nurses Act
• state/territory Nursing and Midwifery Regulatory Authority standards of practice
• scope of nursing practice decision making framework

• Contribute to health teaching
• Use language, literacy and numeracy competence required to communicate effectively with client group and record or report client outcomes.
• Use communication skills:

• establishing rapport
• interpreter services
• modification of communication techniques to suit age, gender, spiritual and cultural needs
• questioning skills

• Use interpersonal skills, including working with others, empathy with clients, family and colleagues, using sensitivity when dealing with people and relating to persons from differing cultural, spiritual, social and religious backgrounds

EVIDENCE GUIDE 

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit :

• The individual being assessed must provide evidence of specified essential knowledge as well as skills
• Observation of performance in a work context is essential for assessment of this unit
• Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse

Context of and specific resources for assessment :

• This unit is most appropriately assessed in the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the clinical workplace
• Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible

Method of assessment 

• Observation in the workplace
• Written assignments/projects
• Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
• Questioning - verbal and writing
• Role play/simulation

Access and equity considerations :

• All workers in the health industry should be aware of access and equity issues in relation to their own area of work
• All workers should develop their ability to work in a culturally diverse environment
• In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
• Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Related units :

This unit is recommended to be assessed in conjunction with the following related competency unit:

• HLTAP501B Analyse health information
• HLTEN502B Apply effective communication skills in nursing practice

This competency unit incorporates the content of:

• HLTEN403B Undertake basic client assessment

RANGE STATEMENT 

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.

Preliminary health assessment data collected may include :

• Allergies
• Biographical information
• Client and/or family concerns regarding the illness or disease
• Co-existing health problems
• Current lifestyle patterns and behaviours
• Environmental factors and living circumstances
• Family history of presenting illness or disease in addition to length of symptoms
• Immunisation status
• Medications
• Past medical or surgical condition
• Presenting condition

Clinical nursing interventions or observations include :

• Blood glucose level
• Blood pressure
• Body mass index
• Height and weight
• Neurological observations
• Performance of activities of daily living
• Sensory perception
• Skin colour, integrity and turgor
• Temperature/pulse/respirations
• Urinalysis

Age and gender considerations could include :

• Age of consent
• Body image perceptions
• Confidentiality
• Female health concerns
• Male health concerns
• Maturation and physical development
• Need for parental consent
• Self esteem

Cultural , spiritual or religious data could include :

• Cultural practices
• Culturally appropriate nursing actions
• Need for interpreter services
• Religious beliefs
• Spiritual beliefs
• Views on health and illness

Common terms associated with human behaviour may include :

• Achievement
• Affect
• Emotion
• Mood
• Motivation
• Perception
• Sensation

Factors that influence health related behaviour may include :

• age
• Culture
• Economic
• Educational
• Environmental
• Gender
• Geographical
• Physiological
• Psychological
• Social

The concepts of growth and development may include :

• Cephalocaudal
• Cognitive
• Emotional
• Inclusive
• Interdependent
• Physical
• Proximo-distal
• Simple to complex
• Social

The theorists associated with theories of growth and development may include :

• Erikson
• Freud
• Havighurst
• Maslow
• Piaget

Cognitive and motor development of infants  (0  -1 ) may include :

• Attachment and Bonding
• Emotional development - from excitement to jealousy
• Gross motor skills: rolling, crawling, walking
• Language development
• Memory
• Object permanence
• Percentile charts
• Reflexes
• Relationship development
• Spatial relationships
• Time

Toddler's development may include :

• Assist rather than instruct
• Beginnings of independence and autonomy
• Cause and effect
• Completion of simple puzzles
• Fine motor skills pencil grip, using scissors, pulling up pants, washing hands
• Gross motor skills: walking, running, climbing, riding tricycles
• Love and affection
• Object permanence developing
• Offering choices
• Play alongside other children
• Routines
• Safe environment
• Self feeding

continued  ...

Toddler's development may include  (cont ):

• Sensitivity from adults
• Slow down of physical growth
• Speech
• Temper tantrums
• Toilet training

Preschooler's development may include :

• Construction activities
• Development of fears: dark, accidents
• Egocentric
• Endless questioning
• Fine motor skills: cutting, painting, drawing
• Gross motor skills: running, climbing, jumping, throwing, catching
• Increasing language skills: chatter, sing
• Learning requires the use of physical materials integrated into real life situations
• Need for exploration with in a safe environment
• Physical growth increases
• Playing with other children, actively looking for playmates
• Pre - operational phase (Piaget)
• Require acceptance and encouragement
• Rich and creative imagination
• Routines
• Safe environment
• Social interactions

School aged child's development may include :

• Abstract and more flexible thought
• Appearance of secondary sexual characteristics
• Concrete operational phase (Piaget)
• Cooperation
• Fear, depression and detachment
• Generosity
• Height, weight and changes in proportion
• Helpfulness
• Independence
• Injury prevention
• Participation in team sports
• Peer group
• Permanent teeth
• Playground pecking order
• Problem solving skills
• Recognition of individual needs
• Self concept
• Self esteem
• Social self
• Timing and coordination

Adolescent development may include :

• Abstract thinking
• Appreciation for double meanings and symbolism
• Body proportions
• Changes in height and weight - growth spurts
• Dating - behaviour, rejection and first love
• Emancipation from parents
• Formal operation phase (Piaget)
• Formation of Personal identity
• Identity V Role confusion (Erikson)
• Menstruation
• Muscle development
• Puberty
• Safety, protection and support
• Self image
• Sexual development

Major adolescent issues may include :

• Alcohol consumption - binge drinking
• Career path
• Eating disorders
• Employment
• Gender identity
• 'Generation gap'
• Juvenile delinquency/crime
• Peer pressure
• Rape
• Road accidents
• Safe sex
• Smoking
• Substance use and abuse
• Teenage pregnancy
• Teenage suicide

Early , middle and older adult activities may include :

• 'Empty Nest'
• Children grow up and leave home
• Community work
• Community work
• Contribution to society/future generations
• Death of family members
• Developing a career
• Economic independence
• Finding a partner
• Grandparenthood
• Marriage
• Marriage disenchantment
• Menopause
• Mentors for younger generations
• Parent hood
• Reduction in Progesterone
• Retirement

Nursing record or reports may include :

• Care plans
• Client referrals
• Clinical pathways
• Completion of client based assessment tools and observation charts
• Computerised reporting
• Drug orders
• Integrated notes
• Nursing notes
• Resident classification records
• Test results
• Written instructions

Biomedical equipment may include :

• ECG machine/monitor
• Glass/tympanic/thermometer
• Glucometer
• Manual/electronic sphygmomanometer
• Peak flow meter
• Pencil torch
• Pulse oximeter
• Stethoscope
• Timing device with second hand
• Urine testing kit
• Weighing scales

Validations of findings include :

• Checking of reading with a registered nurse, as appropriate
• Checks/comparisons on baseline observations
• Elimination of artefacts
• Use of manual versus mechanical; observations
• Visual and verbal assessment of the client