HLTEN405B - Implement basic nursing care Competency Mapping Template

Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

HLTEN405B Mapping and Delivery Guide
Implement basic nursing care

Version 1.0
Issue Date: April 2024

Qualification	-	Unit of Competency	HLTEN405B - Implement basic nursing care
Description	This unit describes the skills and knowledge required to contribute to the nursing care of clients in a range of health environments
Employability Skills	This unit contains Employability Skills
Learning Outcomes and Application	The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirementsEnrolled/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
Duration and Setting	X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.
Prerequisites/co-requisites	Not Applicable
Competency Field

Development and validation strategy and guide for assessors and learners		Student Learning Resources	Handouts Activities	Slides PPT	Assessment 1	Assessment 2	Assessment 3	Assessment 4
Elements of Competency	Performance Criteria
Element: Establish and maintain therapeutic relationships with clients	Provide appropriate introductions and explanations prior to all nursing interventions Identify and use appropriate language and interpersonal skills to ensure that the diverse needs of clients and health care settings Conduct the client advocate role within the Enrolled/Division 2 nurse's scope of practice Work effectively with clients from a range of cultural, spiritual and religious backgrounds, taking action to address cultural factors that may impact on nursing practice Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice
Element: Identify client needs relating to individualised nursing care	Identify actual and potential nursing care needs in consultation/collaboration with the client Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse Identify client nutritional needs in consultation/ collaboration with client and their significant others
Element: Assist clients in activities of daily living	Explain to client the importance of hygiene and grooming to achieving health outcomes Assist clients to address hygiene, dressing and grooming needs Describe conditions which affect the oral cavity and demonstrate effective oral hygiene to client Assist clients with their diet and fluid intake and ensure client's nutritional needs are met in consultation/collaboration with registered nurse Apply strategies to assist clients with diet and fluid intake Recognise and manage emergency situations associated with diet and fluid intake Assist clients with key aspects of elimination Explain and demonstrate to clients key factors associated with fluid balance and bowel charts Assist with respiratory function especially deep breathing and coughing exercises Use appropriate measures to promote comfort, rest and sleep
Element: Assist with movement of clients	Apply the principles and techniques of safe manual handling when assisting clients with movement Actively encourage clients to contribute to their own mobility Implement the principles of 'no-lift' policy when assisting clients with movement Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved Identify and describe to clients factors contributing to the formation of decubitus ulcers Apply practices to avoid breakdown of pressure areas Identify common pressure area sites with reference to the needs of each individual client Use and explain appropriate strategies to prevent and manage decubitus ulcers
Element: Prepare clients for procedures	Provide each client with a full explanation regarding preparation for specific procedures Incorporate health teaching into practice within role responsibility Maintain privacy and dignity of client throughout Complete documentation as per organisation policy and procedures Observe validity of consent and report any concerns to the registered nurse, as appropriate
Element: Contribute to nursing care in consultation/ collaboration with registered nurse	Participate in the implementation of a plan of nursing care in line with duty of care and Occupational Health and Safety policies and procedures Identify and apply safe work place procedures as per OH&S policies and organisation policies and procedures Identify and apply infection control principles in all work activities Prioritise work activities to meet acuity of client needs in consultation/collaboration with a registered nurse Work in a manner that maintains the client's privacy and dignity and demonstrates best practice based on a full range of relevant information including scientific rationale Undertake nursing procedures as delegated within the nursing team and scope of practice in consultation/collaboration with a registered nurse Apply strategies to promote comfort, rest and sleep Assist with the implementation of appropriate nursing actions to prevent and manage decubitus ulcers in consultation/collaboration with a registered nurse Implement appropriate action to address urgent needs in consultation/collaboration with a registered nurse and document and report as appropriate Maintain documentation and reporting requirements as per organisation policies and procedures
Element: Monitor and evaluate clients during care	Maintain ongoing observation and assessment during nursing care Observe and document changes in client independence or pain tolerance within scope of Enrolled/Division 2 Nurse practice Record and report changes in condition/baseline data/behaviour to the registered nurse, as appropriate Document evidence of client outcomes in nursing care plan Respond to and report situations of risk to registered nurse Identify and respond appropriately to signs and symptoms of common emergency situations Demonstrate respect for the client's attitudes and values in regard to resuscitation Use emergency codes correctly Initiate CPR according to organisation procedures
Element: Evaluate own contribution to nursing care	Evaluate nursing care in consultation/collaboration with the client and the multidisciplinary team Evaluate nursing care in light of client outcomes Document and report all aspects of client care provided by self

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 following assessment in simulation laboratory 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, prior to assessment in the workplace

Method of assessment	Observation in the work place of clinical performance Written assignments/projects Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Questioning verbal and written 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 units: HLTAP401B Confirm physical health status HLTEN402B Communicate effectively in a nursing role

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, 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:

Discharge policy and planning requirements

Documentation and reporting requirements

Legislation relating to medication administration

Lifespan approach to anatomy and physiology

Microbiology and pathogenesis relating to nosocomial infection

Opportunities to address issues of waste minimisation, environmental responsibility and sustainable practice

Organisation policies and procedures

Risk identification related to episodic care:

age

anaesthesia and surgery

cognitive status

deep vein thrombosis/pulmonary embolism

immobility

length of stay

mental illness

non-compliance

nutritional status

pain

presence of morbidity

Risk prevention strategies

active/passive exercises

asepsis/standard precautions

falls assessment

maintenance of skin integrity

pressure area care

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 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

Handle challenging behaviour and refusal of treatment

Meet nutritional needs

Meet risk minimisation needs

Promote comfort

Undertake observation and assessment

Use effective communication skills

Undertake nursing interventions/procedures.

mobility:

manual handling/risk assessment

assist with mobility

positioning/active and passive exercises

feeding a client

specimens:

collection of specimens

urinalysis

rest and sleep

bed making

bathing and showering

pressure area care

eye toilet

nasal toilet

perineal toilet

oral hygiene

dressing and undressing

assistance with eating and drinking

maintaining skin integrity

nebulisers, puffers, peak flow assessment, oxygen administration and oximetry

basic life support

nasogastric and gastrostomy feeding

ostomy care

established tracheostomy care



The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance

Therapeutic relationships include:	Nurse/client Nurse/significant other Client/client Nurse/nurse Nurse/multidisciplinary health care team

Actual and potential nursing care that clients may need assistance with:	Hygiene and toileting Elimination/incontinence Physical comfort Sleep disturbances Health education Oral/dental care Immobility Respiration and circulation Fluid and nutritional deficits Pain Wounds - acute and chronic Stress Underlying medical condition Social emotional and financial issues Sensory deficits Cognitive deficits

Risks or potential risks due to hospitalisation/medical treatment may include:	Adverse reactions Shock/haemorrhage Deep vein thrombosis/pulmonary embolism Nosocomial infection Skin tears/pressure ulcer formation Constipation Loss of muscle tone Slips and falls Social isolation Sleep deprivation Challenging behaviour Refusal of treatment Workplace harassment and aggression and violence

Risk prevention strategies:	Recording of allergies Monitoring of client vital sign Other monitoring as required eg. fluid balance, blood sugar levels Pressure area care Anti-emboli stockings/DVT prophylaxis Aseptic technique/standard precautions Passive and active exercises Bed rails Assistance with transferring

The broad principles of manual handling may include:	Body mechanics Organisation policy and procedures Risk minimisation and 'no-lift' policies Back care Ergonomics State/territory Occupational Health and Safety Act Safe operation of equipment

Manual handling techniques must include:	Transferring a client from bed to chair and vice versa Assisting a client to ambulate Moving a client in the bed Client falls

Factors contributing to mobility may include:	Client health status Active and passive exercises Equipment availability Culture Environment

Transfer/mobility devices/equipment may include:	Hoist Wheelchairs Walking frames Slide sheets Walking aids

Purpose of hygiene and grooming may include:	Cleanliness Assessment of skin Self esteem Social aspects

Hygiene may include:	Showing and showering trolley Bed bath/sponge Bath

Grooming may include:	Brushing hair Facial shavings Nail care Cleaning and applying glasses Cleaning and inserting hearing aid Application of make up and jewellery Application of prostheses and orthoses

Conditions of the oral cavity may include:	Dry mouth, gums and tongue Halitosis Pale or bleeding mucosa and gums including tongue Candida albicans (thrush) Herpes Simplex/cold sores Ulcers of the mucosa, gums and tongue Ill fitting dentures Deviations of tongue alignment Stomatitis/Gingivitis Cleft palate/lip Dental caries

Oral hygiene may include:	Brushing teeth Mouth wash/gargle Mouth toilet Application of lip emollient

Key aspects of assisting a client with diet and fluid intake may include:	Comfort Hygiene and elimination needs are met Serviette provided/presentation of meal Meal size and food preference Placement of meal to facilitate appetite Suitable utensils and condiments offered Rate of eating and fluids offered Encourage independence Meal completion, hygiene and comfort needs are met Visual and hearing impairment considered Swallowing impairment Cognitive and physical impairment Fasting and restricted fluids

Strategies to assist may include:	Position and environment

Key aspects of elimination may include:	Bedpan/Urinal/Commode Enemas/Suppositories Perineal care Continence aids Privacy and dignity Positioning and hygiene Disposal of waste Odour control

Key factors associated with fluid balance and bowel charts may include:	Intake and output measurements in millilitres, totalled with positive/negative balance calculated on fluid balance chart Diet intake chart Accurate and continuous documentation Description of stool on bowel chart Report variances as per environmental policies

Factors contributing to formation of decubitus ulcers may include:	Intrinsic Extrinsic

Strategies for prevention and management of decubitus ulcers may include:	Pressure risk assessment scales Use of pressure relieving devices Regular observation of skin condition\ Repositioning

Rest may include:	Power naps/meditation/relaxation techniques

Factors that promote and impede comfort, rest and sleep may include:	Routine and position Environment/equipment Emotional state/pain physical state Medication Nursing interventions Visitors/other clients

Bed making may include:	Occupied Unoccupied

Risk minimisation strategies for nurses may include:	Hazard assessment/reporting/risk minimisation Implementation of 'No-Lift' policy Maintenance of regular contact with members of the care team/nurse supervisor Referral of self appropriately for debriefing/counselling Attention to own health and rest requirements Strategies for addressing workplace harassment/aggression and violence

Recording and reporting requirements includes:	Admission and discharge documentation Client progress notes Fluid balance charts Conscious/neurological observations Specific charting as required Verbal handovers/case meetings Critical incident reporting to senior staff Incident reports Understanding of work roles of other health team members Occupational health and safety hazard reporting

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
Provide appropriate introductions and explanations prior to all nursing interventions
Identify and use appropriate language and interpersonal skills to ensure that the diverse needs of clients and health care settings
Conduct the client advocate role within the Enrolled/Division 2 nurse's scope of practice
Work effectively with clients from a range of cultural, spiritual and religious backgrounds, taking action to address cultural factors that may impact on nursing practice
Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice
Identify actual and potential nursing care needs in consultation/collaboration with the client
Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate
Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse
Identify client nutritional needs in consultation/ collaboration with client and their significant others
Explain to client the importance of hygiene and grooming to achieving health outcomes
Assist clients to address hygiene, dressing and grooming needs
Describe conditions which affect the oral cavity and demonstrate effective oral hygiene to client
Assist clients with their diet and fluid intake and ensure client's nutritional needs are met in consultation/collaboration with registered nurse
Apply strategies to assist clients with diet and fluid intake
Recognise and manage emergency situations associated with diet and fluid intake
Assist clients with key aspects of elimination
Explain and demonstrate to clients key factors associated with fluid balance and bowel charts
Assist with respiratory function especially deep breathing and coughing exercises
Use appropriate measures to promote comfort, rest and sleep
Apply the principles and techniques of safe manual handling when assisting clients with movement
Actively encourage clients to contribute to their own mobility
Implement the principles of 'no-lift' policy when assisting clients with movement
Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved
Identify and describe to clients factors contributing to the formation of decubitus ulcers
Apply practices to avoid breakdown of pressure areas
Identify common pressure area sites with reference to the needs of each individual client
Use and explain appropriate strategies to prevent and manage decubitus ulcers
Provide each client with a full explanation regarding preparation for specific procedures
Incorporate health teaching into practice within role responsibility
Maintain privacy and dignity of client throughout
Complete documentation as per organisation policy and procedures
Observe validity of consent and report any concerns to the registered nurse, as appropriate
Participate in the implementation of a plan of nursing care in line with duty of care and Occupational Health and Safety policies and procedures
Identify and apply safe work place procedures as per OH&S policies and organisation policies and procedures
Identify and apply infection control principles in all work activities
Prioritise work activities to meet acuity of client needs in consultation/collaboration with a registered nurse
Work in a manner that maintains the client's privacy and dignity and demonstrates best practice based on a full range of relevant information including scientific rationale
Undertake nursing procedures as delegated within the nursing team and scope of practice in consultation/collaboration with a registered nurse
Apply strategies to promote comfort, rest and sleep
Assist with the implementation of appropriate nursing actions to prevent and manage decubitus ulcers in consultation/collaboration with a registered nurse
Implement appropriate action to address urgent needs in consultation/collaboration with a registered nurse and document and report as appropriate
Maintain documentation and reporting requirements as per organisation policies and procedures
Maintain ongoing observation and assessment during nursing care
Observe and document changes in client independence or pain tolerance within scope of Enrolled/Division 2 Nurse practice
Record and report changes in condition/baseline data/behaviour to the registered nurse, as appropriate
Document evidence of client outcomes in nursing care plan
Respond to and report situations of risk to registered nurse
Identify and respond appropriately to signs and symptoms of common emergency situations
Demonstrate respect for the client's attitudes and values in regard to resuscitation
Use emergency codes correctly
Initiate CPR according to organisation procedures
Evaluate nursing care in consultation/collaboration with the client and the multidisciplinary team
Evaluate nursing care in light of client outcomes
Document and report all aspects of client care provided by self

Forms

Assessment Cover Sheet

HLTEN405B - Implement basic nursing care

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

HLTEN405B - Implement basic nursing care

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:

Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

HLTEN405B Mapping and Delivery Guide Implement basic nursing care

Version 1.0 Issue Date: April 2024

Evidence Required

Submission Requirements

Assessment Tasks

Observation Checklist

Forms

Assessment Cover Sheet

HLTEN405B - Implement basic nursing care

Assessment task 1: [title]

Assessment Record Sheet

HLTEN405B - Implement basic nursing care

HLTEN405B Mapping and Delivery Guide
Implement basic nursing care

Version 1.0
Issue Date: April 2024