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

Assessment should replicate workplace conditions as far as possible

Simulations may be used to represent workplace conditions as closely as possible

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 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 the following related competency units:

HLTAP501B Analyse health information

HLTEN509B Apply legal and ethical parameters to nursing practice

HLTEN502B Apply effective communication skills in nursing practice

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 at a complex level

Deviations from the normal anatomy and physiology of:

gastrointestinal system

nervous system

special senses

endocrine system

urinary system

reproductive system

fluid/electrolyte balance

musculoskeletal system

Demonstrated knowledge of:

common disorders/conditions

basic associated diagnostic tests

common drugs and nursing management of disorders relating to:

gastrointestinal

nervous

eye and ear

endocrine

urinary and reproductive systems

musculoskeletal

respiratory

cardiovascular

skin

Ethical guidelines including confidentiality, duty of care

Mediation/negation/conflict resolution

Medical terminology

Microbiology and infection control

Non-judgmental attitude

Nursing procedures associated with these disorders

Organisation policy and procedure

Pathophysiology

Referral options and resources available in community/health care setting

Social justice principles

Occupational health and safety (OHS) 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

Participate as a member of a health care team

Perform clinical nursing interventions

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 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 nursing interventions/procedures specific to complex client care such as:

aseptic technique

basic life support

blood specimen collection (venepuncture)

insertion of a naso-gastric tube

insertion of indwelling catheter

isolation and barrier nursing

nasogastric and gastrostomy feeding

ostomy care

oxygen administration

recording of 12 lead electrocardiogram

removal of staples and sutures

tracheostomy care

wound management

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.

Common disorders/conditions may include:

Musculoskeletal disorders/conditions

Skin disorders/conditions

Cardiovascular disorders/conditions

Respiratory system disorder/condition

Gastrointestinal disorder/condition

Ear disorder/condition

Eye disorder/condition

Nervous system disorder

Endocrine disorder/condition

Urinary system disorder/condition

Reproductive system disorder/condition

Common gastrointestinal disorders/conditions may include:

Adhesions/appendicitis/paralytic ileus/peritonitis

Bowel obstruction

Carcinoma

Cholelithiasis/cholecystitis

Cirrhosis/hepatitis

Constipation

Dietary intolerance disorders

Diarrhoea

Diverticulitis

Fistula/haemorrhoids/anal fissure

Gastritis/gastroenteritis/peptic ulcer

Hernia

Inflammatory bowel diseases/irritable bowel syndrome

Pancreatitis

Stoma (long term ostomy sites)

Stomatitis

Common terminology associated with gastrointestinal disorders/conditions may include:

Dyspepsia

Malaena/diarrhoea

Impaction/constipation

Nausea/vomiting

Nasogastric tube/percutaneous endoscopic gastrostomy tube (PEG)

Intravenous therapy/parenteral nutrition

Barium studies/biopsy

Endoscopy/gastroscopy

Colonoscopy/sigmoidoscopy

Liver function test (LFT)

X-ray, ultrasound and scan

Cholangiogram

Specific nursing interventions associated with gastrointestinal disorders /conditions may include:

PEG tube feeding

Nasogastric tube feeding

Removal of nasogastric tube

Application of colostomy/ileostomy appliance

Faeces specimen collection

Drugs commonly used for gastrointestinal disorders/conditions may include:

Antacids/antiemetics/anti-ulcer drugs

Absorbents/antiflatulents

Digestive enzymes

Antidiarrheals

Laxatives/aperients

Common musculoskeletal disorders/conditions may include:

Osteoarthritis

Septic arthritis/rheumatoid arthritis

Back pain

Bursitis

Fracture

Gout

Soft tissue injury/trauma

Osteomyelitis/osteoporosis

Terminology associated with common musculoskeletal disorders/conditions may include:

Amputation

Ankylosis

Carpal tunnel syndrome

Casts

Degenerative

Fixation - internal/external

Inflammatory

Prosthesis/splints

Strains/sprains

Tendinitis

Traction

Fractures

Common skin conditions and terminology may include:

Acne

Bacterial skin infections

Basal cell carcinoma/squamous cell carcinoma

Burns

Carbuncle/furuncle

Cysts

Dermatitis/eczema/psoriasis

Excoriation/abrasion

Keloid

Malignant melanoma

Neoplasm - malignant and benign

Papules/pustules/vesicles

Parasitic infections/infestations

Pruritis

Scabies

Ulcer

Urticaria

Common cardiovascular disorders may include:

Angina pectoris

Atherosclerosis/arteriosclerosis

Aneurysm

Coronary artery disease/congestive cardiac failure (CCF)

Hypertension

Myocardial infarction

Peripheral vascular disease (PVD)

Pulmonary oedema

Deep vein thrombosis

Terminology associated with common cardiovascular disorders/conditions may include:

Cardiac arrhythmias

Embolus/thrombus

Ischaemia/infarction

Phlebitis

Stenosis

Hypertensive/hypertensive

Bypass

Cardiac Doppler/cardiac function stress test/stress testing

Cardiac echogram/ECG

Scan/Ultrasound/x-ray

Angioplasty

Cardiac catheterisation/Cardiac artery bypass

Varicose veins

Infarction

Grafts

Serum enzymes

Oedema

Daily weight

The role of the Enrolled/Division 2 Nurse in Cardiopulmonary resuscitation may include:

Identification of cardiac arrest

Call for help

Commence CPR

Assist medical aid as directed

Contribute to documentation

Emotional and physical support of other clients

Seek debriefing

Common medications may include:

Antihypertensives

Anticoagulants

Anti arrhythmic

Vasodilators

Calcium channel blockers

Digoxin

Narcotic analgesics

Quinine sulphate

Common respiratory system disorders/conditions may include:

Asthma

Bronchitis

Carcinoma

Chronic Obstructive Airways Disease/Chronic Obstructive Pulmonary Disease/Chronic Airways Limitation

Emphysema

Haemothorax/pneumothorax

Legionnaires

Pneumonia/pleurisy

Pulmonary embolus/embolism

Tuberculosis

Upper respiratory tract infection

Viral influenza

Blood dyscrasias may include:

Anaemias

Leukaemia

Bleeding disorders

Thalassaemia

Terms associated with respiratory conditions:

Blood gases/pulse oximetry/oxygen saturation levels

Bronchoscopy/tracheostomy

Continuous Positive Airways Pressure (CPAP)

Cyanosis

Intercostal catheters/underwater seal drainage

Mechanical ventilation

Naso and oropharyngeal airway

Pulmonary function test/peak flow/spirometry

Scans/chest x-rays

Sputum/expectoration

Oxygen and aerosol therapies may include:

Oral and/or nasal suctioning

Nebuliser therapy

Metered dose inhalers

Spacers

Oxygen therapy

Nasal cannula/nasal catheter

Hudson mask/Venturi mask

Head box

Deep breathing and coughing

Postural drainage

Medications may include:

Bronchodilators

Expectorants

Cough suppressants

Steroids

Antibiotics

Anti-mucolytics

Topical anaesthetics

Oxygen

Common nervous system disorders/conditions may include:

Alzheimer's disease

Epilepsy/Peripheral neuropathy

Head injury/Meningitis/Encephalitis

Parkinson's disease

Cerebral palsy

Multiple sclerosis

Herpes zoster

Cerebrovascular accident

Transient ischaemia attack

Motor neuron disease/Guilliane-Barre syndrome

Common terminology associated with nervous system disorders/conditions may include:

Ataxia

Aura

Concussion/headache

Dyskinesia

Irritability/seizure

Intracranial pressure

Neuralgia

Confusion/orientation

Glasgow coma scale/neurological observations

Muscle tone

Hyperextension/reflex/atonic

Grand mal (clonic- tonic)/Petit mal

Electro encephalograph (EEG)

Sensory deficit/motor deficit

Photophobia

Spasm

Lumbar puncture/epidural/echoencephalography

Vestibular function test/myelogram

Cerebral atrophy

Dementia

Computerised Tomography (CT Scan)

Magnetic Resonance Imaging (MRI)

Paraplegia/quadriplegia/tetraplegia

Paraesthesia/phantom pain/referred pain

Specific nursing interventions associated with nervous system disorders /conditions must include:

Measure, record and monitor neurological observations

Drugs commonly used for nervous system disorders/conditions may include:

Analgesics/antipyretics

Non steroidal anti-inflammatory drugs

Anticonvulsants/antiparkinsonians

Cholinergics/anticholinergics

Steroids

Adrenergics/adrenergic blockers

Neuromuscular blockers/anaesthetics

Common eye disorders/conditions/terminology may include:

Blepharitis/corneal ulcer

Cataracts/glaucoma

Colour blindness

Conjunctivitis/iritis

Ectropion/entropion

Flash burns

Foreign body to eye

Intraocular lens implant

Jaundice

Macular degeneration

Myopia/hyperopia/presbyopia/hemianopia

Ophthalmology

Refractive examination/ophthalmoscopic examination

Retinal detachment/retinal neuropathy

Strabismus/nystagmus

Tonometry/optical

Trachoma

Trauma to eye

Visual acuity/visual field

Specific nursing interventions associated with eye disorders /conditions may include:

Eye toilet

Application of eye pad

Administration of eye drops

Drugs commonly used for eye disorders/conditions may include:

Miotics/mydriatics

Beta blockers

Carbonic anhydrase inhibitors

Antibiotics

Ophthalmic vasoconstrictors/artificial tears

Diuretics

Specific nursing interventions associated with endocrine disorders /conditions must include:

Blood glucose level monitoring

Subcutaneous administration of insulin

Administration of oral glycaemics

Specific nursing interventions associated with reproductive/urinary system disorders /conditions must include:

Mid-stream specimen of urine

24-hour urine collection/bladder washout

Removal of indwelling urethral catheter

Contraceptives

Catheter specimen of urine

Drugs commonly used for reproductive system disorders/conditions may include:

Hormone replacement

Antibiotics

Antifungal drugs

Neoplastic drugs

Advocacy skills include:

Freedom of informed choice

Access to services

Personal safety and security

Rights and needs relating to culture

Freedom from discrimination

Rights and needs related to holistic care practices

Appropriate terminology

Advocacy on behalf of client may be to:

Management

Other staff

Other agencies

Family/carer/community

Other health services/professionals/government departments

Advocacy may include:

Meeting the needs in the context of organisation requirements

Awareness of potential conflict between client's needs and organisation requirements.