HLTEN504C - Implement and evaluate a plan of nursing care Competency Mapping Template
Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners
HLTEN504C Mapping and Delivery Guide Implement and evaluate a plan of nursing care
Version 1.0 Issue Date: May 2024
Qualification
-
Unit of Competency
HLTEN504C - Implement and evaluate a plan of nursing care
Description
This competency unit describes the knowledge and skills required to implement nursing care plans for individual clients and evaluate the care provided 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
Pre-requisite unitThis unit must be assessed after successful achievement of pre-requisite: HLTAP401B Confirm physical health status
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
Identify actual and potential nursing care needs in consultation/collaboration with the client
Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse
Introduce and explain all nursing interventions, using appropriate language and interpersonal skills to address the diverse needs of clients and health care settings
Establish and maintain a safe environment through effective communication with clients, family and carers
Advocate for clients within the Enrolled/Division 2 nurse 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
Incorporate health teaching into practice within role responsibility
Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice
Element: Assist client 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
Identify client nutritional needs in consultation/ collaboration with client and their significant others
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 and principles of 'no-lift' policy when assisting clients with movement
Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate
Actively encourage clients to contribute to their own mobility
Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved
Identify common pressure area sites with reference to the needs of each individual client and implement appropriate strategies to prevent and manage decubitus ulcers
Identify and describe to clients factors contributing to the formation of decubitus ulcers and practices to avoid breakdown of pressure areas
Element: Prepare clients for procedures
Provide each client with a full explanation regarding preparation for specific procedures
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: Provide nursing care to meet identified needs
Participate in the implementation of a plan of nursing care in line with duty of care and WHS policies and procedures
Monitor the application of safe workplace procedures as per WHS policies and organisation policies and procedures
Monitor the application of infection control principles in all work activities
Prioritise work activities to meet acuity of client needs and maintain a balanced approach to own workload
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
Apply strategies to promote comfort, rest and sleep
Implement appropriate nursing actions to prevent and manage decubitus ulcers in consultation/ collaboration with a registered nurse
Implement appropriate immediate action to address urgent needs and document and report as appropriate
Implement risk prevention strategies appropriate to delivery of nursing care
Maintain accurate documentation and adhere to reporting requirements to support safe practice as per organisation policies and procedures
Element: Monitor and evaluate clients during care
Maintain ongoing observation and assessment during nursing care
Monitor the use of diagnostic tools and document results
Monitor and evaluate client progress and changes implemented within the nursing role
Assess 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: Prepare the client for discharge in consultation/ collaboration with registered nurse
Clarify client needs for community support services on discharge and 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
Complete documentation as per policy and procedure
Element: Evaluate nursing care provided
Evaluate own contribution to nursing care in consultation/collaboration with the client and registered nurse
Evaluate implementation of plan of nursing care in consultation/collaboration with the multidisciplinary team and/or registered nurse
Evaluate nursing care in light of potential and actual client outcomes
Evaluate risk prevention and management strategies applied in delivery of nursing care
Demonstrate an understanding of implications and risks related to alterations in normal physiological functioning and hospitalisation, and may relate to problems of the body systems
Document and report all aspects of evaluation of nursing care provided
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 may include:
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 and writing
Role play
Simulation - access to simulation clinical setting/environment (laboratory)
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 the following related competency units:
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
Cross cultural communications
Deviations from normal anatomy and physiology
Discharge policy and planning requirements
Documentation and reporting requirements, including mandatory reporting requirements
Environment policy and procedure
Factors that promote and impede comfort, sleep and rest
Legislation relating to medication administration
Lifespan approach to anatomy and physiology
Maintaining a safe environment
Manual handling and 'no lift' policy
Microbiology and pathogenesis relating to nosocomial infection
Work health and safety (WHS)
Organisation policies and procedures
Purpose of hygiene and grooming
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/universal precautions
falls assessment
maintenance of skin integrity
pressure area care
Safe work procedures and manual handling
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
nebulisers, puffers, peak flow assessment, oxygen administration and oximetry
basic life support
nasogastric and gastrostomy feeding
ostomy care
established tracheostomy care
Demonstrate professional conduct, skills and knowledge
Identify and address risk minimisation needs
Meet nutritional needs
Participate as a member of a health care team
Promote comfort
Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues
Undertake admission and discharge processes
Undertake observation and assessment
Use advanced 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 interpersonal skills required, including working with others, empathising with clients, family and colleagues, using sensitivity when dealing with people and an ability to relate to persons from differing cultural, spiritual, social and religious backgrounds
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
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.
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 includes:
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
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/universal 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 Work Health and Safety (WHS) 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
Assisting a client with diet and fluid intake may include ensuring:
Comfort
Hygiene and elimination needs 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 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 aspects 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
Admission and discharge may include:
Admission documentation/application of client identification
Collection of data
Care of valuables/Identification of belongings
Orientation to unit
Diet and fluids need identified
Identify and storage of current medication/s
Commence discharge plan
Return belongings and medications
Documentation of time of discharge
Appointments for follow up
Ensure transport organised
Risk minimisation strategies or 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
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
Work Health and Safety (WHS) hazard reporting
Safe work practices must include:
Personal Protective Equipment
Duty of Care
Needle stick injury
Cleaning, decontamination and storage of equipment
Fire and evacuation procedures
Standard precautions
Critical incident
Workplace harassment/Aggression and Violence
Manual Handling
Principles of Infection Control must include:
Hand washing
Standard precautions
Handling of specimens
Body systems include:
Cardiovascular system
Gastrointestinal tract
Urinary tract
Musculoskeletal system
Nervous system
Endocrine system
Integumentary system
Reproductive system
Emergency situations may include:
Choking and aspiration
Burn/scald
Allergic reaction
Cardiac arrest
Family structure may include:
Nuclear
Extended and blended
Single parent
Same gender parents
Communal
Cohabitative
Foster/Adoptive
Cultural factors that influence nursing care may include:
Gender of carer/health professionals
Dress code
Dietary preferences
Spiritual practices
Strict hygiene practices
Refusal of treatment and drugs
Taboos
Concept of personal space
Personal possessions
Traditional care of the people eg. elderly/children/disabled
Strategies to incorporate spiritual beliefs into nursing practice may include:
Accommodation of prayer times
Fasting
Chapel
Quiet rooms
Pastoral care
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 actual and potential nursing care needs in consultation/collaboration with the client
Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse
Introduce and explain all nursing interventions, using appropriate language and interpersonal skills to address the diverse needs of clients and health care settings
Establish and maintain a safe environment through effective communication with clients, family and carers
Advocate for clients within the Enrolled/Division 2 nurse 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
Incorporate health teaching into practice within role responsibility
Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice
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
Identify client nutritional needs in consultation/ collaboration with client and their significant others
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 and principles of 'no-lift' policy when assisting clients with movement
Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate
Actively encourage clients to contribute to their own mobility
Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved
Identify common pressure area sites with reference to the needs of each individual client and implement appropriate strategies to prevent and manage decubitus ulcers
Identify and describe to clients factors contributing to the formation of decubitus ulcers and practices to avoid breakdown of pressure areas
Provide each client with a full explanation regarding preparation for specific procedures
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 WHS policies and procedures
Monitor the application of safe workplace procedures as per WHS policies and organisation policies and procedures
Monitor the application of infection control principles in all work activities
Prioritise work activities to meet acuity of client needs and maintain a balanced approach to own workload
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
Apply strategies to promote comfort, rest and sleep
Implement appropriate nursing actions to prevent and manage decubitus ulcers in consultation/ collaboration with a registered nurse
Implement appropriate immediate action to address urgent needs and document and report as appropriate
Implement risk prevention strategies appropriate to delivery of nursing care
Maintain accurate documentation and adhere to reporting requirements to support safe practice as per organisation policies and procedures
Maintain ongoing observation and assessment during nursing care
Monitor the use of diagnostic tools and document results
Monitor and evaluate client progress and changes implemented within the nursing role
Assess 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
Clarify client needs for community support services on discharge and 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
Complete documentation as per policy and procedure
Evaluate own contribution to nursing care in consultation/collaboration with the client and registered nurse
Evaluate implementation of plan of nursing care in consultation/collaboration with the multidisciplinary team and/or registered nurse
Evaluate nursing care in light of potential and actual client outcomes
Evaluate risk prevention and management strategies applied in delivery of nursing care
Demonstrate an understanding of implications and risks related to alterations in normal physiological functioning and hospitalisation, and may relate to problems of the body systems
Document and report all aspects of evaluation of nursing care provided
Forms
Assessment Cover Sheet
HLTEN504C - Implement and evaluate a plan of 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
HLTEN504C - Implement and evaluate a plan of 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