Application
This unit describes the skills and knowledge required to contribute to the care of the person with an acute health problem by performing clinical nursing skills and interventions that support the person’s health care needs and assist them to regain optimal function and lifestyle.
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.
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
Elements define the essential outcomes | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Identify impact of acute health problems on a person, family or carer. | 1.1 Identify actual and potential health issues of the person presenting with an acute health problem using information from a preliminary health assessment and in discussion with relevant interdisciplinary health care team members. 1.2 Explain to the person, family or carer the potential physical and psychological impacts of acute health problems on daily living activities. 1.3 Identify the pathophysiology of the person’s underlying or presenting condition, and confirm with the person, family or carer. |
2. Contribute to planning care for a person with acute health problems. | 2.1 Contribute effectively to discussions about the care of the person with registered nurse and other members of the health team. 2.2 Gather information and accurately document and report changes in the person’s condition to appropriate interdisciplinary health care team members. |
3. Perform nursing interventions to support health care of a person with acute health problems. | 3.1 Assist in providing care for the person with a compromised airway including clearing of airways and interpreting health status using monitoring devices. 3.2 Provide care to the person requiring nutrition administered through a feeding tube or intravenous line. 3.3 Use critical thinking and problem-solving approaches in prioritising and modifying nursing interventions to reflect changes in the person’s condition. 3.4 Contribute to the person’s understanding of health care provided to assist them to regain optimal function through nursing interventions and health education. 3.5 Observe the person to identify any psychological support and care required due to the impact of acute health problems. 3.6 Ensure nursing interventions for pre- and post-procedure care for the person are in accordance with organisation policy and procedures. |
4. Contribute to pre- and post-operative nursing care of a person. | 4.1 Contribute to pre-operative nursing management of the person for specific surgical procedures. 4.2 Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications. 4.3 Contribute to post-anaesthetic observation of the person following surgery including identifying deterioration when the person is not regaining consciousness. 4.4 Assist the person recovering from a range of anaesthesia to regain optimal health status, and take appropriate actions to reduce risks associated with immobility. 4.5 Promote the person’s post-operative comfort using pain management strategies and nursing care actions. |
5. Contribute to an emergency response in the acute care environment. | 5.1 Identify and confirm the roles and responsibilities of members of the emergency response team. 5.2 Prepare and check emergency equipment. 5.3 Identify emergency situations and respond to first aid requests from emergency response team, including accessing and preparing drugs used during advanced cardiopulmonary resuscitation. |
Evidence of Performance
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 nursing work in accordance with Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines
analysed health information and the clinical presentation of 1 person in the workplace or simulated environment to reach an accurate conclusion on possible health care planning and nursing interventions related to their acute health condition, in consultation with a registered nurse
performed nursing interventions for 1 person undergoing a surgical procedure in the workplace, including pre-operative preparation and post-operative care
implemented nursing interventions in the workplace or in a simulated environment specific to care of 1 person with acute health problems.
Evidence of Knowledge
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:
acute health problems including:
acute renal disorders
acute gastrointestinal disorders
acute neurological disorder
acute pain
acute respiratory disorders
acute unconscious state
angina
burns
cellulitis
deep vein thrombosis, venous thromboembolism
dehydration
fractures
haemorrhage
head injury
myocardial infarction
renal calculi
sepsis
shock
holistic approach to care in the acute care environment including nursing interventions and outcomes
clinical manifestations of acute disease states and illnesses requiring complex nursing interventions
emergency management protocols for first aid procedures and cardiac and respiratory arrest
pre- and post-operative nursing management
equipment used in acute care environments
post-operative pain management strategies
post-anaesthetic and post-operative observations, which may include:
level of consciousness and awareness of deterioration when the person is not regaining consciousness
fluid intake - intravenous (IV), central venous catheter (CVC), total parenteral nutrition (TPN), oral, nasogastric (NG)
complications of acute bed rest
risk assessment of patient’s stability on their feet
how to perform complex interventions including:
tracheostomy suctioning
underwater seal drainage (UWSD) tube management
intercostal catheter care
how to monitor a person with medical devices including:
continuous positive airway pressure (CPAP) and Bilevel positive airway pressure (BiPAP)
peripherally inserted central catheter (PICC)/midline management
principles of surgical nursing and associated surgical procedures and related terminology including:
elective/emergency surgery
general, local, epidural and spinal anaesthetic and peripheral nerve block
amputation
open reduction
hip replacement
craniotomy
tonsillectomy
appendectomy
laparotomy
hysterectomy
prostatectomy
cataract extraction
internal bleeding due to trauma.
Assessment Conditions
Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. 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:
monitoring device for oxygen therapy measurements
wound drains suction equipment
dressing packs
personal protective equipment
organisation policy and procedures on which the candidate bases the planning
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.
Foundation Skills
The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance.
Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.