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.
ELEMENT | PERFORMANCE CRITERIA |
Elements define the essential outcomes | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Collect and interpret health data. | 1.1 Introduce self and explain processes before commencing nursing assessment activities. 1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies. 1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment. 1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics. 1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state. 1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs. 1.7 Clarify the emotional and physical needs of the family or carer in supporting the person. 1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range. 1.9 Communicate immediately all deterioration concerns about the person to registered nurse. |
2. Undertake admission and discharge procedures for a person. | 2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures. 2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge. 2.3 Identify community support services and resources to assist in planning for discharge. 2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals. |
3. Contribute to planning the nursing care of a person. | 3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required. 3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs. 3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation. |
4. Contribute to ongoing development of individual nursing care plans. | 4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan. 4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress. 4.3 Ensure nursing care plan is based on principles of best practice and risk assessment. 4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person. |
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 nursing work in accordance with Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines
performed nursing admission and discharge procedures for 2 different people in the workplace as per organisation policy and procedures
conducted holistic clinical health assessment on 2 different people in the workplace or in a simulated environment including:
blood glucose monitoring
oxygen saturation level
body mass index (BMI) or waist hip ratio
integumentary assessment
urinalysis
neurological observations including reflexes
neurovascular observations and assessment of peripheral circulation
pain assessment (including chest pain)
developed at least 1 nursing care plan in the workplace or in a simulated environment based on holistic health assessment undertaken with a real person.
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:
admission and discharge planning processes and documentation required
developmental stages of childhood:
physical growth and psychosocial, cognitive and motor development of the toddler and the pre-school and school aged child
physical growth and cognitive and motor development of infants 0-12 months
role of play in a child’s development
impact of hospitalisation on child and family
developmental stages of adolescence and common health issues for adolescents
developmental stages of adulthood and major activities related to each stage
impact of infertility on people
approaches to understanding human growth and development
influences of genetics and environment on development
family health care needs
gender-specific health care needs
how to use equipment for health assessment and data collection
how to assist a person in activities of daily living including identified aids to assist these activities
how to perform clinical measurements and/or assessments for:
blood glucose level
blood pressure
body mass index or waist hip ratio
height and weight
level of consciousness
pupil reaction
neurological reflexes
peripheral circulation
sensory perception and identified personal aids and devices required for hearing or sight
skin colour, integrity and turgor
temperature, pulse, respirations
urinalysis
human growth and development
interpretation and analysis of a person’s health-related information
principles of health assessment
problem solving strategies and techniques for conducting health assessment
how to recognise a deteriorating patient and determine levels of consciousness
how and when to raise issues of concern about a person’s deterioration
resources for the Core Standards for nurses who support people with a disability (NSW Family and Community Services)
Person Centred Health Care Assessments and the Development of Health Care Plans Core Standard for Practitioners
Mealtime Management for Nurses Practice Package
wellness approach to health, including physiology and psychosocial aspects
variations in health needs and activities of daily living across the person’s lifespan.
Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. The following conditions must be met for this unit:
using suitable facilities, equipment and resources in line with the Australian Nursing and Midwifery Accreditation Council’s Standards including:
appropriate biomedical equipment to undertake measurement or monitoring of vital signs and BMI
neurological assessment tools
urinalysis test strips
oximeter
blood glucose monitoring device and test strips
scenario based nursing care plans, charts and progress notes used for simulation
data collection instruments
organisation policy and procedures on which the candidate bases the planning process
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.