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

HLTEN415B Mapping and Delivery Guide
Deliver nursing care to acute care clients

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency HLTEN415B - Deliver nursing care to acute care clients
Description This unit of competency describes the skills and knowledge required of Enrolled/Division 2 nurses in contributing to the care of a person with an acute health problem
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: Identify the impact of acute health problems on the client and their family.
  • Identify the clinical manifestations of presenting acute health problem(s)
  • 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
       
Element: Contribute to planning care for the client with acute health problems
  • Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy
  • Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy
  • Accurately gather, document and report changes in client condition to appropriate health care team members
  • Document information gathered from client and family to assist in development of the care plan
  • 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
  • Implement client discharge procedure in line with organisation policy and procedures
  • Advocate for clients in health and/or community settings
       
Element: Perform nursing interventions to support health care of clients with acute health problems
  • 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
  • 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 own nursing interventions according to client needs
  • Reflect pre- and post-procedure care in nursing interventions
       
Element: Contribute to an emergency response
  • Confirm the roles and responsibilities of members of the emergency response team
  • Participate in performing emergency resuscitation techniques
       
Element: Contribute to pre-operative nursing care of a client
  • 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 care of a pre-operative client
  • Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications
  • Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor
       
Element: Contribute to post-operative nursing care of a client
  • Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse
  • Accurately gather, document and report changes in client condition to appropriate health care team member
  • Provide nursing care for post-operative clients
  • Contribute to observations of the client undergoing blood transfusion
  • Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea
  • Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse
  • Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures
  • Ensure client is attending to post operative exercises
       


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 a simulated clinical work environment and under the normal range of clinical environment conditions, prior to assessment in the 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 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 competency unit:

HLTAP401B Confirm physical health status

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:

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

Awareness and understanding of potential post operative complications

Clinical manifestations of acute disease states/illnesses

Concepts of homeostasis

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

Legal requirements for practice

Members of health care team

Organisation policy and procedures, guidelines and protocols

Pre and post operative nursing management

Principles of surgical nursing

Surgical procedures and related terminology

Workplace health and safety legislation

Workplace Health and Safety legislation

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

Apply problem solving skills, including use of tools and techniques to solve problems, analyse information and make decisions that require discretion and confidentiality

Perform acute clinical nursing interventions/procedures specific to acute client care

client history/assessment

discharge planning

pre-operative preparation

post-operative care

health education

observations

check vital signs - respiratory status, profusion status, urinalysis, blood sugar level, temperature status, oxygen saturation and pain tolerance assessment

Participate as a member of a health care team

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

Use advanced oral communication skills (language competence) required to fulfil job roles as specified by the organisation/service, including:

interviewing techniques

asking questions

active listening

asking for clarification from consumer or other persons where appropriate

negotiating solutions

acknowledging and responding to a range of views

Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation/service using a level of skill ranging from reading and understanding client reports and documentation to completion of written reports

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 may include the following:

Acute renal disorders

Acute abdomen

Acute neurological disorder

Acute pain

Acute respiratory disorders

Acute unconscious state

Angina

Burns

Cellulitis

Deep Vein thrombosis

Dehydration

Elective/emergency surgery (post operative phase)

Fractures

Haemorrhage

Head injury

Myocardial infarction

Renal calculi

Sepsis

Shock

Tropical diseases

Wounds

Acute clinical nursing interventions could include:

Assist achievement of activities of daily living

Acute admission procedure

Acute wound management

Airway management

Application of anti embolism stockings

Observation and reporting of acute pain

Assessment/observation of level of consciousness

Assessment/observation of respiratory function

Complications of acute bed rest

Discharge of client

First aid

Fluid balance recording

Incentive spirometry and peak flow measurements

Neurovascular observations

Pre operative observations, exercises and care

Post operative observations, exercises and care

Preparation for medical procedure

Preparation for surgical procedure

Pulse oximetry

Tracheostomy care (established stoma)

Transfer of client - intra-facility

Transfer/evacuation of client to another facility

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 attitude, active listening and use of culturally appropriate communication methods (verbal and non-verbal)

Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines

Observations may include, but are not limited to:

Respiratory status assessment (ie. Rate, rhythm, depth and sound)

Cardiovascular status assessment ( ie. Pulse, blood pressure)

Temperature status assessment

Oxygen saturation (ie. Triflow, peak flow, oxygen therapy)

Urinalysis

Faecal assessment

Blood sugar level

Client history may include:

Pre-existing medical conditions

Allergies

Current history

Diagnostic procedures/investigations

Allied health team recommendations

Current medication

Continence status

Skin integrity

Mobility

Nutritional status

Hydration status

Psychosocial needs

Next of kin

Previous surgery

Pre-operative assessment data may include:

Vital signs

Allergies

Age, height, weight

Urinalysis

Hydration/nutritional status

Medical/surgical history (including family history)

Prescribe and non-prescribed medications

Patterns of drug use/smoking/alcohol

Specific preparation may include:

Fasting

Skin preparation

Appropriate dress for surgical procedure

Removal of jewellery and safe storage

Administration of prescribed pre-medications

Denture removal (if necessary)

ID band/allergy ID

Check documentation is complete, including signed consent

Removal of sensory aids eg. hearing aid, glasses if required

Drugs commonly used pre-operatively may include:

Sedatives/hypnotics

Anticholinergics

Topical analgesia

Anti-angina medication

Bronchodilators

Post operative pain management strategies may include:

Patient controlled analgesia (PCA)

Narcotic infusion

Epidural analgesia

Topical analgesia

Oral analgesics

Subcutaneous/intramuscular injection analgesia

Post anaesthetic and post-operative observations may include:

Level of consciousness

Vital signs

Intravenous therapy

Indwelling catheters

Neurovascular observations

Skin colour

Fluid output - urinary, wound drainage, suction, vomitus

Indwelling catheter position

Urine output

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
Identify the clinical manifestations of presenting acute health problem(s) 
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 
Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy 
Accurately gather, document and report changes in client condition to appropriate health care team members 
Document information gathered from client and family to assist in development of the care plan 
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 
Implement client discharge procedure in line with organisation policy and procedures 
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 
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 own 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 
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 care of a pre-operative client 
Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications 
Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor 
Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse 
Accurately gather, document and report changes in client condition to appropriate health care team member 
Provide nursing care for post-operative clients 
Contribute to observations of the client undergoing blood transfusion 
Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea 
Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse 
Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures 
Ensure client is attending to post operative exercises 

Forms

Assessment Cover Sheet

HLTEN415B - Deliver nursing care to acute care clients
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

HLTEN415B - Deliver nursing care to acute care clients

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: