HLTEN512B - Implement and monitor nursing care for clients with acute health problems
Assessor Resource
HLTEN512B Implement and monitor nursing care for clients with acute health problems
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 Enrolled/Division 2 nurses to contribute to the care of the person with an acute health problem by performing nursing interventions that support their health care needs and assist them to regain optimal function and lifestyle
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
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 work place
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning - verbal or written
Role play
Simulation/ virtual clinical setting (laboratory) to accommodate learning
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 units:
HLTEN505B Contribute to the complex nursing care of clients
HLTEN415B Deliver nursing care to acute care clients
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:
Activities of daily living
Acute care nursing interventions and outcomes
Acute rehabilitation strategies and techniques
Admission and discharge processes
Anatomy and physiology
Application of nursing theory
Clinical manifestations of acute disease states/illnesses
Complex nursing interventions
Concepts of homeostasis
Critical thinking and problem solving process
Documentation principles
Effective communication skills/medical terminology, including common terminology associated with surgery
Emergency care and first aid procedures
Emergency management protocols for cardiac and/or respiratory arrest
Equipment used in acute care environments
Ethical guidelines including confidentiality, duty of care and public liability
Fundamental nursing interventions
Health teaching principles and strategies
Legal requirements for practice
Members of health care team
Occupational health and safety legislation
Organisation policy and procedures, guidelines and protocols
Pathophysiology
Pre and post operative nursing management
Principles of surgical nursing
Reflective practice
Surgical procedures and related terminology
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 problem solving skills, including use of tools and techniques to solve problems, analyse information and make decisions that require discretion and confidentiality
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
Participate as a member of a health care team
Perform acute clinical nursing interventions/procedures specific to acute client care
client history/assessment
discharge planning
emergency interventions
pre-operative preparation
post-operative care
health education
observations
blood transfusion care
Check vital signs - respiratory status, perfusion status, urinalysis, blood sugar level, temperature status, oxygen saturation and pain tolerance assessment
Use oral communication skills (language competence) required to fulfil job roles as specified by the health environment. Advanced oral communication skills include interviewing techniques, asking questions, active listening, asking for clarification from client or other persons, negotiating solutions, acknowledging and responding to a range of views
Use written communication skills (literacy competence) required to fulfil job roles as specified by health environment. The level of skill may range from reading and understanding client reports and documentation to completion of written reports
Use interpersonal skills including working with others, empathising 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.
Health care settings may include:
Hospitals
Residential aged care facilities
Respite centres
Short/long stay centres
Community setting
Rural and remote settings
Plans of care could include:
Nursing care plans
Clinical pathways
Treatment plans
Medical notes
Client notes
Manual and electronic storage systems
Resident classification records
Acute health problems include the following:
Acute renal disorders
Acute gastrointestinal disorders
Acute neurological disorder
Acute pain
Acute respiratory disorders
Acute unconscious state
Angina
Burns
Cellulitis
Deep Vein thrombosis
Dehydration
Elective cosmetic surgery
Fractures
Haemorrhage
Head injury
Myocardial infarction
Plastic/reconstructive surgery
Renal calculi
Sepsis
Shock
Tropical diseases
Wounds
Acute clinical nursing interventions may include:
Achievement of activities of daily living
Acute admission procedure
Acute wound management
Airway management
Application of anti embolism stockings
Assessment and management of acute pain
Assessment/observation of level of consciousness
Assessment/observation of respiratory function
Care of client with chest pain
Care of client with drainage tubes/systems
Care of client with nausea and vomiting
Care of client with a cast
Care of client with traction devices
Circulation observations
Complications of acute bed rest
Discharge of client
First aid
Fluid balance recording
Incentive spirometry and peak flow measurements
Monitoring blood transfusion
Monitoring of intravenous therapy
Neurovascular observations
Post operative observations, exercises and care
Pre operative observations, exercises and care
Preparation for medical procedure
Preparation for surgical procedure
Pulse oximetry
Removal of sutures/staples
Review of cardio-pulmonary resuscitation
Stabilising of client with retrieval team
Tracheostomy care (established stoma)
Transfer of client - intra facility
Transfer/evacuation of client to another facility
Vascular observations
Common terminology associated with surgery may include:
Elective/emergency
General/local/epidural/spinal anaesthetic
Caudal/peripheral nerve block
Debridement
Skin graft
Amputation
Open reduction
Hip replacement
Craniotomy
Tonsillectomy
Appendicectomy
Laparotomy
Hysterectomy
Prostatectomy
Cataract extraction
Haemorrhage
Deep vein thrombosis
When communicating/caring for a client, the following may need to be considered:
Any physical or mental problems which may hinder communication (such as deafness or dementia, or disease processes)
Individual consideration of the following socio-economic, physiological variables will be addressed (social, gender, emotional, intellectual, language, culture)
All verbal and non-verbal interactions with client and colleagues in a range of appropriate interpersonal context
Effective communication skills include non judgemental attributes, active listening, using culturally appropriate communication methods, non-verbal behaviour to indicate understanding of what is being said, responses that are culturally appropriate
Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines
Vital signs may include, but are not limited to:
Respiratory status assessment (ie. rate, rhythm, depth and sound)
Perfusion status assessment (ie. pulse, blood pressure)
Potential complications of blood transfusion may include:
Pain at intravenous site and arm
Loin pain
Urticaria (hives)
Nausea and/or vomiting
Headache
Flushing, chills and/or fever
Anxiety
Tachycardia
Wheezing, progressing to cyanosis
Haematuria
Anaphylactic reaction/shock
Cardiac arrest
Death
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
Clarify the clinical manifestations of acute health problems on body systems
Clarify the physical and/or psychological impacts of acute health problems on activities of daily living through discussion with the client and/or family (with client consent)
Confirm understanding of the pathophysiology of the client's underlying/presenting condition
Identify actual and potential health issues of a client presenting with an acute health problem through discussion of information gained from a preliminary health assessment with the appropriate members of the health care team
Use a problem solving approach to assess the impact of the acute health problem on the client and their family and the achievement of activities of daily living
Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client
Maintain confidentiality in line with facility policy and procedures
Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy
Assess health status of clients with an acute episode
Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy
Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan
Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team
Explain the rationale for the planned care and therapeutic interventions in assisting the client achieve optimal health outcomes
Implement client discharge procedure in line with organisation policy and procedures
Accurately gather, document and report changes in client condition to appropriate health care team members
Advocate for clients in health and/or community settings
Undertake nursing interventions based on predetermined plans of care
Ensure nursing interventions reflect client needs and individuality
Perform nursing interventions with respect for the dignity of the client
Reflect consideration of cultural and religious issues in the performance of nursing interventions
Encourage the client and/or their significant others to assist in the performance of nursing interventions if able
Consider physical, psychological and social needs in the performance of nursing interventions
Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements
Use critical thinking and problem solving approaches in undertaking client/s care
Administer medications safely and based on knowledge of principles of drug actions and side effects in accordance with organisation policies and procedures
Assist clients to meet their activities of daily living
Address gender and age issues in the performance of nursing interventions
Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements
Contribute to and support health teaching plans for the client with an acute health problem
Identify appropriate psychological support and care for individual clients
Report and document emergency situations according to policy and procedure
Identify and prioritise nursing interventions according to client needs
Reflect pre- and post-procedure care in nursing interventions
Confirm the roles and responsibilities of members of the emergency response team
Prepare and/or check the equipment on the emergency trolley
Access, in response to request from emergency response team, drugs commonly used during emergency resuscitation (including drugs for anaphylaxis)
Participate in performing emergency resuscitation techniques
Contribute to collection of pre-operative client health assessment data, addressing all relevant factors
Assist in preparation for specific surgical procedures
Contribute to the nursing management of a pre-operative client
Monitor and report on actions and side effects of drugs commonly used pre-operatively
Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures
Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications
Contribute to post-anaesthetic observation of a client following surgery
Apply appropriate post-operative discomfort and pain management strategies as per care plan
Provide nursing management for post-operative clients
Apply knowledge of available drugs commonly used post-operatively for the relief of pain and nausea
Apply appropriate nursing actions to promote client comfort
Confirm the rationale for performing a blood transfusion
Contribute to observations of the client undergoing blood transfusion
Work with an awareness of potential complications of blood transfusion
Take appropriate precautions relating to bodily fluids
Forms
Assessment Cover Sheet
HLTEN512B - Implement and monitor nursing care for clients with acute health problems
Assessment task 1: [title]
Student name:
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I declare that the assessment tasks submitted for this unit are my own work.
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Result: Competent Not yet competent
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Assessment Record Sheet
HLTEN512B - Implement and monitor nursing care for clients with acute health problems
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Assessment task 1: [title] Result: Competent Not yet competent
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Feedback to student:
Overall assessment result: Competent Not yet competent