The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements Enrolled/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 |
Not Applicable
ELEMENT | PERFORMANCE CRITERIA |
1. Identify the impact of acute health problems on the client and their family | 1.1 Clarify the clinical manifestations of acute health problems on body systems 1.2 Clarify the physical and/or psychological impacts of acute health problems on activities of daily living through discussion with the client and/or family (with client consent) 1.3 Confirm understanding of the pathophysiology of the client's underlying/presenting condition 1.4 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 1.5 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 1.6 Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client 1.7 Maintain confidentiality in line with facility policy and procedures |
2. Contribute to planning care for the client with acute health problems | 2.1 Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy 2.2 Assess health status of clients with an acute episode 2.3 Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy 2.4 Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan 2.5 Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team 2.6 Explain the rationale for the planned care and therapeutic interventions in assisting the client achieve optimal health outcomes 2.7 Implement client discharge procedure in line with organisation policy and procedures 2.8 Accurately gather, document and report changes in client condition to appropriate health care team members 2.9 Advocate for clients in health and/or community settings |
3. Perform nursing interventions to support health care of clients with acute health problems | 3.1 Undertake nursing interventions based on predetermined plans of care 3.2 Ensure nursing interventions reflect client needs and individuality 3.3 Perform nursing interventions with respect for the dignity of the client 3.4 Reflect consideration of cultural and religious issues in the performance of nursing interventions 3.5 Encourage the client and/or their significant others to assist in the performance of nursing interventions if able 3.6 Consider physical, psychological and social needs in the performance of nursing interventions 3.7 Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements 3.8 Use critical thinking and problem solving approaches in undertaking client/s care 3.9 Administer medications safely and based on knowledge of principles of drug actions and side effects in accordance with organisation policies and procedures 3.10 Assist clients to meet their activities of daily living 3.11 Address gender and age issues in the performance of nursing interventions 3.12 Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements 3.13 Contribute to and support health teaching plans for the client with an acute health problem 3.14 Identify appropriate psychological support and care for individual clients 3.15 Report and document emergency situations according to policy and procedure 3.16 Identify and prioritise nursing interventions according to client needs 3.17 Reflect pre- and post-procedure care in nursing interventions |
4. Contribute to an emergency response | 4.1 Confirm the roles and responsibilities of members of the emergency response team 4.2 Prepare and/or check the equipment on the emergency trolley 4.3 Access, in response to request from emergency response team, drugs commonly used during emergency resuscitation (including drugs for anaphylaxis) 4.4 Participate in performing emergency resuscitation techniques |
5. Contribute to pre-operative nursing care of a client | 5.1 Contribute to collection of pre-operative client health assessment data, addressing all relevant factors 5.2 Assist in preparation for specific surgical procedures 5.3 Contribute to the nursing management of a pre-operative client 5.4 Monitor and report on actions and side effects of drugs commonly used pre-operatively 5.5 Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures 5.6 Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications |
6. Contribute to post-operative nursing care of a client | 6.1 Contribute to post-anaesthetic observation of a client following surgery 6.2 Apply appropriate post-operative discomfort and pain management strategies as per care plan 6.3 Provide nursing management for post-operative clients 6.4 Apply knowledge of available drugs commonly used post-operatively for the relief of pain and nausea 6.5 Apply appropriate nursing actions to promote client comfort |
7. Contribute to nursing care of the client receiving a blood transfusion | 7.1 Confirm the rationale for performing a blood transfusion 7.2 Contribute to observations of the client undergoing blood transfusion 7.3 Work with an awareness of potential complications of blood transfusion 7.4 Take appropriate precautions relating to bodily fluids |
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 Clinical manifestations of acute disease states/illnesses Complex nursing interventions Concepts of homeostasis Critical thinking and problem solving process 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 Health teaching principles and strategies Legal requirements for practice Members of health care team Occupational health and safety legislation Organisation policy and procedures, guidelines and protocols Pathophysiology Pre and post operative nursing management Principles of surgical nursing Reflective practice Surgical procedures and related terminology |
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 Participate as a member of a health care team Perform acute clinical nursing interventions/procedures specific to acute client care client history/assessment discharge planning emergency interventions pre-operative preparation post-operative care health education observations blood transfusion care Check vital signs - respiratory status, perfusion status, urinalysis, blood sugar level, temperature status, oxygen saturation and pain tolerance assessment 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 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 |
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 | 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 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 units: HLTEN505B Contribute to the complex nursing care of clients HLTAP501B Analyse health information This competency unit incorporates the content of: HLTEN415B Deliver nursing care to acute care clients |
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 include the following: | Acute renal disorders Acute gastrointestinal disorders Acute neurological disorder Acute pain Acute respiratory disorders Acute unconscious state Angina Burns Cellulitis Deep Vein thrombosis Dehydration Elective cosmetic surgery Fractures Haemorrhage Head injury Myocardial infarction Plastic/reconstructive surgery Renal calculi Sepsis Shock Tropical diseases Wounds |
Acute clinical nursing interventions may include: | Achievement of activities of daily living Acute admission procedure Acute wound management Airway management Application of anti embolism stockings Assessment and management of acute pain Assessment/observation of level of consciousness Assessment/observation of respiratory function Care of client with chest pain Care of client with drainage tubes/systems Care of client with nausea and vomiting Care of client with a cast Care of client with traction devices Circulation observations Complications of acute bed rest Discharge of client First aid Fluid balance recording Incentive spirometry and peak flow measurements Monitoring blood transfusion Monitoring of intravenous therapy Neurovascular observations Post operative observations, exercises and care Pre operative observations, exercises and care Preparation for medical procedure Preparation for surgical procedure Pulse oximetry Removal of sutures/staples Review of cardio-pulmonary resuscitation Stabilising of client with retrieval team Tracheostomy care (established stoma) Transfer of client - intra facility Transfer/evacuation of client to another facility Vascular observations |
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 attributes, active listening, using culturally appropriate communication methods, non-verbal behaviour to indicate understanding of what is being said, responses that are culturally appropriate Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines |
Vital signs may include, but are not limited to: | Respiratory status assessment (ie. rate, rhythm, depth and sound) Perfusion status assessment (ie. pulse, blood pressure) Temperature status assessment Oxygen saturation (ie. triflow, peak flow, oxygen therapy) Pain tolerance assessment Urinalysis Faecal assessment Blood sugar level |
Client history may include: | Pre-existing conditions Allergies Current history Diagnostic procedures/investigations Allied health team recommendations Current medication Continence status Skin integrity Muscle/skeletal activity Behavioural characteristics Nutritional status Hydration status Psychological needs Psychosocial needs Next of kin |
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 Identification band 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 |
Drugs commonly used pre-operatively may include: | Sedatives/hypnotics Anticholinergics Muscle relaxants Narcotic analgesia Topical analgesia |
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 Drain tubes/dressings Intravenous therapy Indwelling catheters Neurovascular observations Skin colour Intercostal catheter Underwater seal drainage Fluid intake - intravenous (IV), central venous catheter (CVC), total parenteral nutrition (TPN), oral, nasogastric Fluid output - urinary, wound drainage, suction, vomitus |
Drugs commonly used post-operatively may include: | Analgesia Antiemetic Antibiotic Anti-inflammatory/Anti-coagulants |
Potential complications of blood transfusion may include: | Pain at intravenous site and arm Loin pain Urticaria (hives) Nausea and/or vomiting Headache Flushing, chills and/or fever Anxiety Tachycardia Wheezing, progressing to cyanosis Haematuria Anaphylactic reaction/shock Cardiac arrest Death |
Not Applicable
This unit contains Employability Skills |
Not Applicable