HLTEN503B - Contribute to client assessment and developing nursing care plans assessment tool

Assessor Resource

HLTEN503B
Contribute to client assessment and developing nursing care plans

Assessment tool

Version 1.0
Issue Date: May 2024

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

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

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)

Prerequisites

Not Applicable

Employability Skills

This unit contains Employability Skills

Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.



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

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title] Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

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



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

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice	Yes	No	Comments/feedback
Ensure appropriate introductions and explanations precede all nursing assessment and interventions
Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
Perform other clinical measurements/assessments such as activities of daily living
Record lifestyle patterns and coping mechanisms in documentation
Document current client health practices, issues and needs
Document gender, age, cultural, religious and/or spiritual data in preliminary health assessment
Identify the likely impact of specific health care on the client's health
Involve client in the process of data collection wherever possible
Access client information from appropriate family member or carer (if client is unable)
Identify the emotional and physical needs of family and significant others in supporting the client
Document and report variations from normal on a regular basis
Validate extraordinary findings immediately, document and report abnormalities to the registered nurse
Undertake ongoing client assessment
Collect client-based data for admission and /or discharge planning
Communicate effectively with clients, family and health team members within jurisdictional scope of practice
Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
Follow organisation policies and procedures relating to client participation
Undertake client admission with understanding of processes involved and key issues to be addressed
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
Document client information, such as community resources, to assist in planning for discharge
Accurately record and report admission and discharge information
Accurately interpret information gained from health assessments and observations as being within normal range and/or refer to appropriate health care colleague for interpretation
Report change in client health status in a timely manner to the appropriate health care colleague
Identify the likely cause of any significant variation(s) from normal in relation to providing care
Reflect consideration for age and developmental state of client in performance of clinical nursing assessment
Analyse physiological aspects of human growth and its impact on client health
Reflect the client's interests, physical, emotional and psychosocial needs in documentation
Respect cultural, spiritual and religious wishes during nursing assessment
Use client health history as part of planning care in line with health organisation requirements
Conduct a holistic health assessment reflecting the nursing philosophy or theory of the organisation in consultation/collaboration with a registered nurse
Use appropriate health assessment tools and appropriate terminology in documentation as well as a variety of sources and clinical situations
Use a problem solving approach in the development of care plans for clients
Discuss care requirements with the client and/or their family or significant other to ensure information is accurate
Verify client based information to ensure client's uniqueness and individuality is reflected in the care plan
Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
Record age and gender issues in the development of individualised care plans
Incorporate cultural, spiritual and religious beliefs in the development of individualised care plans
Ensure documentation reflect the client's needs: physical, emotional, spiritual and psychosocial
Ensure nursing care plan addresses principles of best practice and risk assessment and identifies stress management techniques for clients
Identify appropriate community support services to the client
Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice
Ensure client has all requirements for discharge: next GP's appointment; medications; and any referrals
Ensure documentation is completed as per policy and procedure

Forms

Assessment Cover Sheet

HLTEN503B - Contribute to client assessment and developing nursing care plans

Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

Assessor name:

Signature:

Date:

Assessment Record Sheet

HLTEN503B - Contribute to client assessment and developing nursing care plans

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date:

Assessor Resource

HLTEN503B Contribute to client assessment and developing nursing care plansAssessment tool

Version 1.0 Issue Date: May 2024

Prerequisites

Employability Skills

Evidence Required

Submission Requirements

Assessment Tasks

Observation Checklist

Forms

Assessment Cover Sheet

HLTEN503B - Contribute to client assessment and developing nursing care plans

Assessment task 1: [title]

Assessment Record Sheet

HLTEN503B - Contribute to client assessment and developing nursing care plans

HLTEN503B
Contribute to client assessment and developing nursing care plans

Assessment tool

Version 1.0
Issue Date: May 2024