This unit describes the skills and knowledge required to recongise the need for assessment, perform physical examinations and make clinical judgments using critical analysis and specialised knowledge of pathophysiology and clinical assessment processes.

This unit applies to enrolled nurses, registered with the Nursing and Midwifery Board of Australia, seeking specialisation in enrolled nurse work that is carried out in consultation and collaboration with registered nurses and under direct or indirect 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.

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

demonstrated the capacity to analyse changes in a person’s health status, perform physical examinations and make sound clinical judgements for at least 3 different people presenting with a complex condition, illness or injury

assessed health status using the following clinical assessment tools and techniques:

neurological examination, including sensory function and motor responses, reflexes

peripheral vascular system examination

respiratory auscultation and percussion

chest auscultation and percussion

abdomen auscultation and palpation

heart sounds check

interpreted the person’s blood test results for abnormal findings indicating changes in health status.

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:

communication strategies that underpin assessment and communication with the person and other health professionals, including:

appropriate modes of communication for the information being provided

range of interviewing skills

information technology and health technologies to capture clinical data for responsive coordination and dissemination to relevant members of the interdisciplinary health care team

factors for consideration when communicating with people with:

communication-related disabilities

mental health conditions

pharmacological and alcohol addiction or misuse

adverse behavioural responses to unfamiliar environments

person under stress due to situations to themselves or others such as trauma, death and life threatening situations

advanced concepts underpinning human maintenance systems including immunity and homeostasis imbalance causing physical changes associated with:

acidosis/alkalosis

diabetes (hypoglycaemia, hyperglycaemia)

nutirition and hydration/dehydration

cancer treatment

thermostasis (thermoregulation)

infections

poisoning

sepsis

clinical assessment techniques and tools used in a head-to-toe physical body examination:

inspection – uses of the sense of sight to identify specific characteristics of the individual

palpation – utilises use of the sense of touch to determine physical signs.

percussion – use of tapping on an individual's body to evaluate location and density of underlying structures.

auscultation – listening to sounds created by the body using stethoscope

processes for the neurological examination of the sensory function and motor responses including:

cranial nerves

inspection, looking for subtle weakness e.g. tremors, pronator drift

gait abnormalities including scissors, spastic, stoppage and waddling

stance including posture, lordosis, kyphosis and scoliosis

muscular response and muscle strength

dermatomes and related spinal nerves

peripheral neuropathies

sensory function testing: light touch, pain sensation, temperature, proprioception and tactile localisation

stereognosis and graphaesthesia

Romberg test

deep tendon reflexes including how to position a person and use of reflex hammer and comparing left and right side responses

superficial reflexes such as abdominal and cremasteric reflexes

processes for respiratory system examination including

respirations – breathing effort, chest pain associated with breathing, movement of the rib cage for symmetrical or diaphragmatic breathing pattern

auscultation – systematic approach to determine if underlying lung tissue is filled with fluid, air or solid material checking lung fields for bilateral adventitious noises

percussion sounds including:

resonant: heard over the lung fields - air filled spaces- very hollow sound

tympany: heard over the gut area- duller sound- like tapping on a watermelon

dull: heard over bony areas- little transmission of sound

processes for checking heart sounds including:

aortic, pulmonic, Erbs Point, tricuspid and mitral heart sounds

Sound1 represents closure of the atrioventricular (mitral and tricuspid) valves during the beginning of systole

Sound 2 represents closure of the semilunar valves (aortic and pulmonic) valves during the end of systole and beginning of diastole

processes for chest and abdomen examination including:

inspection – described by location (quadrant) visible abdominal masses, and the movement of the chest and abdominal wall

auscultation (for abdomen auscultation is before palpation and percussion) – detection of normal and altered bowel sounds in abdomen, bubbling; rubbing; grating; crackling or vascular bruits

palpation and percussion – depth of palpation (superficial or deep) using the fingertip or flat of the hand for examination of the abdomen for crepitus of the abdominal wall, for any abdominal tenderness, rebound tenderness or for abdominal masses

processes for peripheral vascular system examination including:

inspection – colour of limbs (including when legs are hanging over the edge of the bed), hair loss, ulcers, scars and muscle wasting, lateral side foot and in-between toes

upper limb pulse – subclavaian, carotid, brachial, radial, ulnar and capillary refill time

lower limb pulse – aorta, femoral, popliteal, posterior tibial, doralis pedis and anterior tibial

palpation of the amplitude of arterial pulses bounding, brisk diminished, absent or unable to palpate

checking peripheral pulse and apical pulse for consistency

Allens test to determine patency of the radial and ulnar arteries

processes for skin, hair and nails examination including:

colour, texture, turgor, warmth, moisture distribution, the presence of any lesions or scars

clubbing of the nail beds can be indicative of pulmonary disease

reduced hair distribution on the lower legs can be indicative of cardiovascular disease (check with individual if they use hair removal treatments)

effects of intrinsic factors (such as age, health) and extrinsic factors (such as environment, medications) on person’s condition

how to interpret common blood test results and their meanings as indicators of a health condition or illness including:

Albumin

Arterial Blood Gas (ABG)

Blood Sugar Level (BSL), haemoglobin A1C

Blood Urea Nitrogen (BUN)

Calcium

Cardiac Enzymes (CE)

Cholesterol

Coagulation Studies (Coags)

Erythrocyte Sedimentation Rate (ESR)

Electrolytes (EUC) (Sodium/Potassium/Chloride Urea/Creatinine)

Full Blood Count (FBC)

High-Density Lipoprotein (HDL)

Iron

Low-Density Lipo-protein (LDL)

Magnesium

Phosphorus

Triglycerides

Thryoid Stimulating Hormone (TSH)

Uric acid

how to recognise subtle changes in a person’s condition through knowledge of a person’s patterns of responses and comparing responses over periods of time

principles for recognising a deteriorating patient and raising issues of concern about a person’s deterioration

socio-economic, physiological, emotional and physical variables related to clinical presentation of a person.

Skills must have been demonstrated in the workplace with the addition of simulations and scenarios where the full range of contexts and situations cannot be provided in the workplace. 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:

organisation policy and procedures on which the candidate bases the assessment process.

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.

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.