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

HLTENN004 Mapping and Delivery Guide
Implement, monitor and evaluate nursing care plans

Version 1.0
Issue Date: March 2024


Qualification -
Unit of Competency HLTENN004 - Implement, monitor and evaluate nursing care plans
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to implement nursing care as outlined in a person’s plan of care, evaluate outcomes of care provided, record and report progress, and respond to an emergency situation. This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements. The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. The requirement of the performance evidence to implement and monitor at least 2 different nursing care plans in the workplace must have been demonstrated in simulation before being demonstrated in the workplace and with members of the public. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources in line with the Australian Nursing and Midwifery Accreditation Council’s Standards, including:

simulation manikins for adult, child and infant suitable for demonstration of life support skills

defibrillator or AED

lifting equipment used to manage risks involved in moving and positioning a person

equipment used in deep breathing and coughing exercises

equipment used in active and passive exercises

risk prevention documentation, nursing care plans and progress notes used in the planning of nursing care

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.

Prerequisites/co-requisites
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: Elements define the essential outcomes
       
Element: Prepare a person for care procedures.
  • Explain the procedures, preparation required and timeframe involved and gain the person’s consent.
  • Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.
       
Element: Implement care procedures to meet identified needs.
  • Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.
  • Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.
  • Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.
  • Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.
  • Use appropriate measures to promote the person’s comfort, rest and sleep.
  • Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.
  • Identify and respond appropriately to signs and symptoms of an emergency situation or condition.
       
Element: Monitor a person’s identified care needs.
  • Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.
  • Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.
  • Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.
       
Element: Evaluate outcomes of care provided.
  • Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.
  • Evaluate the person’s progress towards planned outcomes as documented in the care plan.
  • Make required changes to nursing care plan in line with best practice in nursing.
  • Record and report all aspects of the evaluation of nursing care provided.
       
Element: Monitor a person’s identified care needs.
  • Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.
  • Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.
  • Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.
       


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.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Prepare a person for care procedures.

1.1 Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

1.2 Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

2. Implement care procedures to meet identified needs.

2.1 Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

2.2 Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

2.3 Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

2.4 Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

2.5 Use appropriate measures to promote the person’s comfort, rest and sleep.

2.6 Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

2.7 Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

2.8 Use emergency codes correctly and initiate basic life support according to organisation policy and procedures.

3. Monitor a person’s identified care needs.

3.1 Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

3.2 Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

3.3 Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

4. Evaluate outcomes of care provided.

4.1 Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

4.2 Evaluate the person’s progress towards planned outcomes as documented in the care plan.

4.3 Make required changes to nursing care plan in line with best practice in nursing.

4.4 Record and report all aspects of the evaluation of nursing care provided.

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 work in in accordance with Nursing and Midwifery Board of Australia professional standards of practice, codes and guidelines

implemented and monitored at least 2 different nursing care plans in the workplace

evaluated at least 1 nursing care plan in the workplace or in a simulated environment

used emergency codes and performed basic life support in a simulated environment on an adult, child and infant manikin according to organisation policy and procedures.

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:

activities of daily living

factors that promote and impede comfort, sleep and rest

purpose of hygiene and grooming

actual and potential nursing care including:

hygiene and toileting

elimination needs, including procedures used to assist with elimination

incontinence management, including aids or devices

physical comfort

sleep disturbances

oral hygiene including:

teeth brushing

care of dentures

using alcohol-free mouthwash

interdental cleaning

immobility

respiration and circulation

fluid and nutritional deficits

pain

underlying medical condition

sensory deficits, including use of personal aids and devices

cognitive deficits

basic life support including:

how to perform cardiopulmonary resuscitation (CPR)

use of and response to emergency codes

considerations when providing basic life support including

airway obstruction due to body position

appropriate duration and cessation of CPR

appropriate use of an Automatic External Defibrillator (AED)

risk identification related to episodic care:

age

anaesthesia and surgery

cognitive status

deep vein thrombosis, venous thromboembolism, pulmonary embolism

immobility

length of stay

mental health condition

non-compliance

nutritional status

pain

presence of morbidity

risk prevention strategies including:

maintaining a safe environment

preventing falls and falls assessment

promoting active and passive exercises

promoting deep breathing and coughing exercises

maintaining skin integrity and pressure area care

recording and reporting requirements for comprehensive clinical handovers and case meetings.


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.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Prepare a person for care procedures.

1.1 Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

1.2 Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

2. Implement care procedures to meet identified needs.

2.1 Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

2.2 Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

2.3 Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

2.4 Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

2.5 Use appropriate measures to promote the person’s comfort, rest and sleep.

2.6 Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

2.7 Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

2.8 Use emergency codes correctly and initiate basic life support according to organisation policy and procedures.

3. Monitor a person’s identified care needs.

3.1 Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

3.2 Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

3.3 Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

4. Evaluate outcomes of care provided.

4.1 Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

4.2 Evaluate the person’s progress towards planned outcomes as documented in the care plan.

4.3 Make required changes to nursing care plan in line with best practice in nursing.

4.4 Record and report all aspects of the evaluation of nursing care provided.

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
 
Explain the procedures, preparation required and timeframe involved and gain the person’s consent. 
Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures. 
Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes. 
Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown. 
Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs. 
Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises. 
Use appropriate measures to promote the person’s comfort, rest and sleep. 
Actively encourage the person to contribute to their own independence and mobility through active and passive exercises. 
Identify and respond appropriately to signs and symptoms of an emergency situation or condition. 
 
Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices. 
Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload. 
Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures. 
Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care. 
Evaluate the person’s progress towards planned outcomes as documented in the care plan. 
Make required changes to nursing care plan in line with best practice in nursing. 
Record and report all aspects of the evaluation of nursing care provided. 
Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices. 
Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload. 
Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures. 

Forms

Assessment Cover Sheet

HLTENN004 - Implement, monitor and evaluate nursing care plans
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

HLTENN004 - Implement, monitor and evaluate nursing care plans

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: