Undertake basic client assessment Evidence Guide

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Evidence Guide: HLTEN403B - Undertake basic client assessment

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

HLTEN403B - Undertake basic client assessment

What evidence can you provide to prove your understanding of each of the following citeria?

Collect data relating to client health

Ensure appropriate introductions and explanations precede all nursing assessment and interventions
Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
Perform other clinical measurements/assessments such as activities of daily living
Document current client health practices, issues and needs
Document and report variations from normal on a regular basis
Involve client in the process of data collection wherever possible
Undertake ongoing data collection, such as vital signs

Ensure appropriate introductions and explanations precede all nursing assessment and interventions

Completed
Date:

Teacher:

Evidence:

Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client

Completed
Date:

Teacher:

Evidence:

Perform other clinical measurements/assessments such as activities of daily living

Completed
Date:

Teacher:

Evidence:

Document current client health practices, issues and needs

Completed
Date:

Teacher:

Evidence:

Document and report variations from normal on a regular basis

Completed
Date:

Teacher:

Evidence:

Involve client in the process of data collection wherever possible

Completed
Date:

Teacher:

Evidence:

Undertake ongoing data collection, such as vital signs

Completed
Date:

Teacher:

Evidence:

Undertake client assessment for admission and discharge

Collect client-based data for admission and/or discharge planning
Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
Follow organisation policies and procedures relating to client participation
Undertake client admission with understanding of processes involved and key issues to be addressed
Take into account individual's values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate
Document client information, such as community resources, to assist in planning for discharge
Accurately record and report admission and discharge information
Respect cultural, spiritual and religious wishes during nursing assessment

Collect client-based data for admission and/or discharge planning

Completed
Date:

Teacher:

Evidence:

Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors

Completed
Date:

Teacher:

Evidence:

Follow organisation policies and procedures relating to client participation

Completed
Date:

Teacher:

Evidence:

Undertake client admission with understanding of processes involved and key issues to be addressed

Completed
Date:

Teacher:

Evidence:

Take into account individual's values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate

Completed
Date:

Teacher:

Evidence:

Document client information, such as community resources, to assist in planning for discharge

Completed
Date:

Teacher:

Evidence:

Accurately record and report admission and discharge information

Completed
Date:

Teacher:

Evidence:

Respect cultural, spiritual and religious wishes during nursing assessment

Completed
Date:

Teacher:

Evidence:

Contribute to planning nursing care for clients in a health care environment

Contribute to development of nursing care plans within the context of the area of health care and implement in consultation/collaboration with the registered nurse
Communicate effectively with clients, family and health team members within jurisdictional scope of practice
Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
Identify and implement stress management techniques for clients

Contribute to development of nursing care plans within the context of the area of health care and implement in consultation/collaboration with the registered nurse

Completed
Date:

Teacher:

Evidence:

Communicate effectively with clients, family and health team members within jurisdictional scope of practice

Completed
Date:

Teacher:

Evidence:

Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse

Completed
Date:

Teacher:

Evidence:

Identify and implement stress management techniques for clients

Completed
Date:

Teacher:

Evidence:

Prepare for client discharge

Clarify client needs for community support services on discharge and identify appropriate community support services to the client
Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice
Ensure client has all requirements for discharge:

Clarify client needs for community support services on discharge and identify appropriate community support services to the client

Completed
Date:

Teacher:

Evidence:

Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice

Completed
Date:

Teacher:

Evidence:

Ensure client has all requirements for discharge:

Completed
Date:

Teacher:

Evidence:

next GP's appointment

Completed
Date:

Teacher:

Evidence:

medications

Completed
Date:

Teacher:

Evidence:

any referrals

Ensure documentation is completed as per policy and procedure

Ensure documentation is completed as per policy and procedure

Completed
Date:

Teacher:

Evidence:

Work with clients across the life span

Work with an understanding of the different approaches to the concepts of growth and development
Work with an awareness of differing influences on human development, of genetics and environment
When working with clients across the life span, take into account differences in physical growth, cognitive and motor development, psychosocial development and issues associated with different stages of development

Work with an understanding of the different approaches to the concepts of growth and development

Completed
Date:

Teacher:

Evidence:

Work with an awareness of differing influences on human development, of genetics and environment

Completed
Date:

Teacher:

Evidence:

When working with clients across the life span, take into account differences in physical growth, cognitive and motor development, psychosocial development and issues associated with different stages of development

Completed
Date:

Teacher:

Evidence:

Assessed

Teacher: ___________________________ Date: _

Signature: ________________________________________________

Comments:

Instructions to Assessors

Evidence Guide



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 prior to assessment in the clinical workplace 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 workplace Written assignments/projects Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Questioning verbal and writing 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 other related nursing units and with: HLTAP401B Confirm physical health status HLTEN402B Communicate effectively in a nursing role

Required Skills and Knowledge

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:

Admission and discharge planning and policies

Confidentiality and privacy

Effects of biological maturation and ageing processes on body systems and their components

Equipment for use in nursing skills or data collection

Health needs across the lifespanHuman growth and development:

developmental stages of childhood:

physical growth, cognitive and motor development of infants 0-12 months

physical growth, psychosocial development and the cognitive and motor development of the toddler, pre-school and school aged child

role of play in a child's development

the impact of hospitalisation for the child and family

developmental stages and major issues of adolescence

developmental stages of adulthood, major activities related to each stage of adulthood and impact of infertility

variations in activities of daily living across the lifespan

gender specific health care needs

age specific health care needs

family health care needs

cultural, religious and spiritual beliefs and practices related to health status

differing influences of genetics and environment on development

different approaches to understanding human growth and development

In-depth understanding of the structure and functioning of anatomy and physiology of the human body as addressed in unit HLTAP401A Confirm physical health status

Legal and professional standards of practice

Principles of health assessment - problem solving, strategies and techniques for conducting health assessment

Wellness approach to health - physiology and psychosocial

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 documentation principles:

legally compliant recording and reporting

types of data to be collected in health care environment

appropriate terminology

data collection instruments used in health care environments

Apply information technology skills

Apply health care procedures

observations

holistic client assessment

admission and discharge procedures

physical assessment

assessment of activities of daily living

measurements - temperature, pulse, respirations and blood pressure

oximetry, body mass index

specimen collection

urinalysis

neurological observations

neurovascular observations

blood glucose monitoring

assessment of pain

level of consciousness (eg Coma scale)

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

Contribute to health teaching

Monitor clients during procedures

Prepare clients for various procedures

continued ...

Essential skills (contd):

Use language, literacy and numeracy competence required to communicate effectively with client group and record or report client outcomes.

Use communication skills:

establishing rapport

interpreter services

modification of communication techniques to suit age, gender, spiritual and cultural needs

questioning skills

Use interpersonal skills, including working with others, empathy with clients, family and colleagues, using sensitivity when dealing with people and relating to persons from differing cultural, spiritual, social and religious backgrounds

Range Statement



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.

Preliminary health assessment data collected may include:	Biographical information Co-existing health problems Allergies Medications Presenting condition Past medical or surgical condition Current lifestyle patterns and behaviours Client and/or family concerns regarding the illness or disease Family history of presenting illness or disease in addition to length of symptoms Environmental factors and living circumstances Immunisation status

Clinical nursing interventions or observations include:	Skin colour, integrity and turgor Height and weight Body mass index Blood glucose level Temperature/pulse/respirations Blood pressure Sensory perception Performance of activities of daily living Neurological observations Urinalysis

Age and gender considerations could include:	Maturation and physical development Self esteem Body image perceptions Age of consent Need for parental consent Confidentiality Male health concerns Female health concerns

Cultural, spiritual or religious data could include:	Religious beliefs Cultural practices Spiritual beliefs Views on health and illness Culturally appropriate nursing actions Need for interpreter services

Common terms associated with human behaviour may include:	Perception Sensation Emotion Motivation Achievement Affect Mood

Factors that influence health related behaviour may include:	Physiological Psychological Economic Educational Geographical Environmental Social Culture Gender Age

The concepts of growth and development may include:	Simple to complex Cephalocaudal Proximo-distal Inclusive Interdependent Cognitive Physical Social Emotional

The theorists associated with theories of growth and development may include:	Maslow Erikson Freud Piaget Havighurst

Cognitive and motor development of infants (0 - 1) may include:	Percentile charts Reflexes Spatial relationships Time Object permanence Attachment and Bonding Memory Gross motor skills - Rolling, Crawling, Walking Language development Emotional development - from excitement to jealousy Relationship development

Toddler's development may include:	Speech Slow down of physical growth Gross motor skills: walking, running, climbing, riding tricycles Self feeding Toilet training Fine motor skills: pencil grip, using scissors, pulling up pants, washing hands Object permanence developing (cont)

Toddler's development may include (Cont):	Cause and effect Completion of simple puzzles Assist rather than instruct Sensitivity from adults Safe environment Temper tantrums Beginnings of independence and autonomy Play along side other children Offering choices Love and affection Routines

Preschooler's development may include:	Safe environment Physical growth increases Gross motor skills: running, climbing, jumping, throwing, catching Fine motor skills: cutting, painting, drawing Egocentric Increasing language skills : chatter, sing Endless questioning Pre - operational phase (Piaget) Social interactions Construction activities Learning requires the use of physical materials integrated into real life situations Playing with other children, actively looking for playmates Development of fears: dark, accidents Rich and creative imagination Require acceptance and encouragement Need for exploration with in a safe environment Routines

School aged child's development may include:	Participation in team sports Height, weight and changes in proportion Permanent teeth Appearance of secondary sexual characteristics Timing and coordination Injury prevention Concrete operational phase (Piaget) Abstract and more flexible thought Problem solving skills Social self Peer group Playground pecking order Generosity Cooperation Helpfulness Self concept Self esteem Independence Recognition of individual needs Fear, Depression and Detachment

Adolescence development may include:	Puberty Changes in height and weight - growth spurts Body proportions Menstruation Muscle development Sexual development Self image Abstract thinking Appreciation for double meanings and symbolism Formal operation phase (Piaget) Identity V Role confusion (Erikson) Emancipation from parents Formation of Personal identity Dating - behaviour, rejection and first love Safety, protection and support

Major adolescent issues may include:	Teenage Suicide Substance Use and Abuse Safe Sex Teenage Pregnancy Eating Disorders Employment Career path Rape Gender identity 'Generation Gap' Juvenile Delinquency/Crime Road Accidents Alcohol consumption - binge drinking Smoking Peer pressure

Early, middle and older adult activities may include:	Finding a partner Marriage Developing a Career Parent hood Economic Independence Death of family members Children grow up and leave home Contribution to society/future generations Mentors for younger generations Community work Menopause Reduction in Progesterone Marriage disenchantment 'Empty Nest' Retirement Grandparenthood Community work

Nursing record or reports may include:	Completion of client based assessment tools and observation charts Nursing notes Integrated notes Resident classification records Test results Written instructions Drug orders Client referrals Clinical pathways Care plans Computerised reporting

Biomedical equipment may include:	Timing device with second hand Manual/electronic sphygmomanometer Stethoscope Glass/tympanic/thermometer Pulse oximeter Glucometer Weighing scales Pencil torch Peak flow meter ECG machine/monitor Urine testing kit

Validations of findings include:	Visual and verbal assessment of the client Checks/comparisons on baseline observations Use of manual versus mechanical; observations Elimination of artefacts Checking of reading with a registered nurse, as appropriate

Admission and discharge may include:	Admission documentation/application of client identification Collection of data Care of valuables/Identification of belongings Orientation to unit Diet and fluids need identified Identify and storage of current medication/s Commence discharge plan Return belongings and medications Documentation of time of discharge Appointments for follow up Ensure transport organised

NTISthis.com

Evidence Guide: HLTEN403B - Undertake basic client assessment

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

HLTEN403B - Undertake basic client assessment

Collect data relating to client health

Undertake client assessment for admission and discharge

Contribute to planning nursing care for clients in a health care environment

Prepare for client discharge

next GP's appointment

medications

any referrals

Work with clients across the life span

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

Instructions to Assessors

Teacher: ___________________________ Date: _