Deliver nursing care to acute care clients Evidence Guide

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Evidence Guide: HLTEN415B - Deliver nursing care to acute care clients

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

HLTEN415B - Deliver nursing care to acute care clients

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

Identify the impact of acute health problems on the client and their family.

Identify the clinical manifestations of presenting acute health problem(s)
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
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
Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client
Maintain confidentiality in line with facility policy and procedures

Identify the clinical manifestations of presenting acute health problem(s)

Completed
Date:

Teacher:

Evidence:

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

Completed
Date:

Teacher:

Evidence:

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

Completed
Date:

Teacher:

Evidence:

Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client

Completed
Date:

Teacher:

Evidence:

Maintain confidentiality in line with facility policy and procedures

Completed
Date:

Teacher:

Evidence:

Contribute to planning care for the client with acute health problems

Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy
Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy
Accurately gather, document and report changes in client condition to appropriate health care team members
Document information gathered from client and family to assist in development of the care plan
Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan
Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team
Implement client discharge procedure in line with organisation policy and procedures
Advocate for clients in health and/or community settings

Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy

Completed
Date:

Teacher:

Evidence:

Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy

Completed
Date:

Teacher:

Evidence:

Accurately gather, document and report changes in client condition to appropriate health care team members

Completed
Date:

Teacher:

Evidence:

Document information gathered from client and family to assist in development of the care plan

Completed
Date:

Teacher:

Evidence:

Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan

Completed
Date:

Teacher:

Evidence:

Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team

Completed
Date:

Teacher:

Evidence:

Implement client discharge procedure in line with organisation policy and procedures

Completed
Date:

Teacher:

Evidence:

Advocate for clients in health and/or community settings

Completed
Date:

Teacher:

Evidence:

Perform nursing interventions to support health care of clients with acute health problems

Undertake nursing interventions based on predetermined plans of care
Ensure nursing interventions reflect client needs and individuality
Perform nursing interventions with respect for the dignity of the client
Reflect consideration of cultural and religious issues in the performance of nursing interventions
Encourage the client and/or their significant others to assist in the performance of nursing interventions if able
Consider physical, psychological and social needs in the performance of nursing interventions
Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements
Assist clients to meet their activities of daily living
Address gender and age issues in the performance of nursing interventions
Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements
Contribute to and support health teaching plans for the client with an acute health problem
Identify appropriate psychological support and care for individual clients
Report and document emergency situations according to policy and procedure
Identify and prioritise own nursing interventions according to client needs
Reflect pre- and post-procedure care in nursing interventions

Undertake nursing interventions based on predetermined plans of care

Completed
Date:

Teacher:

Evidence:

Ensure nursing interventions reflect client needs and individuality

Completed
Date:

Teacher:

Evidence:

Perform nursing interventions with respect for the dignity of the client

Completed
Date:

Teacher:

Evidence:

Reflect consideration of cultural and religious issues in the performance of nursing interventions

Completed
Date:

Teacher:

Evidence:

Encourage the client and/or their significant others to assist in the performance of nursing interventions if able

Completed
Date:

Teacher:

Evidence:

Consider physical, psychological and social needs in the performance of nursing interventions

Completed
Date:

Teacher:

Evidence:

Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements

Completed
Date:

Teacher:

Evidence:

Assist clients to meet their activities of daily living

Completed
Date:

Teacher:

Evidence:

Address gender and age issues in the performance of nursing interventions

Completed
Date:

Teacher:

Evidence:

Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements

Completed
Date:

Teacher:

Evidence:

Contribute to and support health teaching plans for the client with an acute health problem

Completed
Date:

Teacher:

Evidence:

Identify appropriate psychological support and care for individual clients

Completed
Date:

Teacher:

Evidence:

Report and document emergency situations according to policy and procedure

Completed
Date:

Teacher:

Evidence:

Identify and prioritise own nursing interventions according to client needs

Completed
Date:

Teacher:

Evidence:

Reflect pre- and post-procedure care in nursing interventions

Completed
Date:

Teacher:

Evidence:

Contribute to an emergency response

Confirm the roles and responsibilities of members of the emergency response team
Participate in performing emergency resuscitation techniques

Confirm the roles and responsibilities of members of the emergency response team

Completed
Date:

Teacher:

Evidence:

Participate in performing emergency resuscitation techniques

Completed
Date:

Teacher:

Evidence:

Contribute to pre-operative nursing care of a client

Contribute to collection of pre-operative client health assessment data, addressing all relevant factors
Assist in preparation for specific surgical procedures
Contribute to the nursing care of a pre-operative client
Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications
Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor

Contribute to collection of pre-operative client health assessment data, addressing all relevant factors

Completed
Date:

Teacher:

Evidence:

Assist in preparation for specific surgical procedures

Completed
Date:

Teacher:

Evidence:

Contribute to the nursing care of a pre-operative client

Completed
Date:

Teacher:

Evidence:

Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications

Completed
Date:

Teacher:

Evidence:

Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor

Completed
Date:

Teacher:

Evidence:

Contribute to post-operative nursing care of a client

Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse
Accurately gather, document and report changes in client condition to appropriate health care team member
Provide nursing care for post-operative clients
Contribute to observations of the client undergoing blood transfusion
Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea
Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse
Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures
Ensure client is attending to post operative exercises

Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse

Completed
Date:

Teacher:

Evidence:

Accurately gather, document and report changes in client condition to appropriate health care team member

Completed
Date:

Teacher:

Evidence:

Provide nursing care for post-operative clients

Completed
Date:

Teacher:

Evidence:

Contribute to observations of the client undergoing blood transfusion

Completed
Date:

Teacher:

Evidence:

Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea

Completed
Date:

Teacher:

Evidence:

Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse

Completed
Date:

Teacher:

Evidence:

Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures

Completed
Date:

Teacher:

Evidence:

Ensure client is attending to post operative exercises

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 a simulated clinical work environment and under the normal range of clinical environment conditions, prior to assessment in the 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 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 competency unit: HLTAP401B Confirm physical health status

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:

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

Awareness and understanding of potential post operative complications

Clinical manifestations of acute disease states/illnesses

Concepts of homeostasis

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

Legal requirements for practice

Members of health care team

Organisation policy and procedures, guidelines and protocols

Pre and post operative nursing management

Principles of surgical nursing

Surgical procedures and related terminology

Workplace health and safety legislation

Workplace Health and Safety legislation

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 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

Apply problem solving skills, including use of tools and techniques to solve problems, analyse information and make decisions that require discretion and confidentiality

Perform acute clinical nursing interventions/procedures specific to acute client care

client history/assessment

discharge planning

pre-operative preparation

post-operative care

health education

observations

check vital signs - respiratory status, profusion status, urinalysis, blood sugar level, temperature status, oxygen saturation and pain tolerance assessment

Participate as a member of a health care team

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

Use advanced oral communication skills (language competence) required to fulfil job roles as specified by the organisation/service, including:

interviewing techniques

asking questions

active listening

asking for clarification from consumer or other persons where appropriate

negotiating solutions

acknowledging and responding to a range of views

Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation/service using a level of skill ranging from reading and understanding client reports and documentation to completion of written reports

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.

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 may include the following:	Acute renal disorders Acute abdomen Acute neurological disorder Acute pain Acute respiratory disorders Acute unconscious state Angina Burns Cellulitis Deep Vein thrombosis Dehydration Elective/emergency surgery (post operative phase) Fractures Haemorrhage Head injury Myocardial infarction Renal calculi Sepsis Shock Tropical diseases Wounds
Acute clinical nursing interventions could include:	Assist achievement of activities of daily living Acute admission procedure Acute wound management Airway management Application of anti embolism stockings Observation and reporting of acute pain Assessment/observation of level of consciousness Assessment/observation of respiratory function Complications of acute bed rest Discharge of client First aid Fluid balance recording Incentive spirometry and peak flow measurements Neurovascular observations Pre operative observations, exercises and care Post operative observations, exercises and care Preparation for medical procedure Preparation for surgical procedure Pulse oximetry Tracheostomy care (established stoma) Transfer of client - intra-facility Transfer/evacuation of client to another facility

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 attitude, active listening and use of culturally appropriate communication methods (verbal and non-verbal) Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines

Observations may include, but are not limited to:	Respiratory status assessment (ie. Rate, rhythm, depth and sound) Cardiovascular status assessment ( ie. Pulse, blood pressure) Temperature status assessment Oxygen saturation (ie. Triflow, peak flow, oxygen therapy) Urinalysis Faecal assessment Blood sugar level

Client history may include:	Pre-existing medical conditions Allergies Current history Diagnostic procedures/investigations Allied health team recommendations Current medication Continence status Skin integrity Mobility Nutritional status Hydration status Psychosocial needs Next of kin Previous surgery

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 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 Check documentation is complete, including signed consent Removal of sensory aids eg. hearing aid, glasses if required

Drugs commonly used pre-operatively may include:	Sedatives/hypnotics Anticholinergics Topical analgesia Anti-angina medication Bronchodilators

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 Intravenous therapy Indwelling catheters Neurovascular observations Skin colour Fluid output - urinary, wound drainage, suction, vomitus Indwelling catheter position Urine output

NTISthis.com

Evidence Guide: HLTEN415B - Deliver nursing care to acute care clients

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

HLTEN415B - Deliver nursing care to acute care clients

Identify the impact of acute health problems on the client and their family.

Contribute to planning care for the client with acute health problems

Perform nursing interventions to support health care of clients with acute health problems

Contribute to an emergency response

Contribute to pre-operative nursing care of a client

Contribute to post-operative nursing care of a client

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

Instructions to Assessors

Teacher: ___________________________ Date: _