NTISthis.com

Evidence Guide: HLTEN512B - Implement and monitor nursing care for clients with acute health problems

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

 

HLTEN512B - Implement and monitor nursing care for clients with acute health problems

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

  1. Clarify the clinical manifestations of acute health problems on body systems
  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)
  3. Confirm understanding of the pathophysiology of the client's underlying/presenting condition
  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
  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
  6. Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client
  7. Maintain confidentiality in line with facility policy and procedures
Clarify the clinical manifestations of acute health problems on body systems

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm understanding of the pathophysiology of the client's underlying/presenting condition

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

  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. Assess health status of clients with an acute episode
  3. Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy
  4. Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan
  5. Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team
  6. Explain the rationale for the planned care and therapeutic interventions in assisting the client achieve optimal health outcomes
  7. Implement client discharge procedure in line with organisation policy and procedures
  8. Accurately gather, document and report changes in client condition to appropriate health care team members
  9. 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:

 

 

 

 

 

 

 

Assess health status of clients with an acute episode

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:

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

Explain the rationale for the planned care and therapeutic interventions in assisting the client achieve optimal health outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement client discharge procedure in line with organisation policy and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

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

  1. Undertake nursing interventions based on predetermined plans of care
  2. Ensure nursing interventions reflect client needs and individuality
  3. Perform nursing interventions with respect for the dignity of the client
  4. Reflect consideration of cultural and religious issues in the performance of nursing interventions
  5. Encourage the client and/or their significant others to assist in the performance of nursing interventions if able
  6. Consider physical, psychological and social needs in the performance of nursing interventions
  7. Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements
  8. Use critical thinking and problem solving approaches in undertaking client/s care
  9. Administer medications safely and based on knowledge of principles of drug actions and side effects in accordance with organisation policies and procedures
  10. Assist clients to meet their activities of daily living
  11. Address gender and age issues in the performance of nursing interventions
  12. Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements
  13. Contribute to and support health teaching plans for the client with an acute health problem
  14. Identify appropriate psychological support and care for individual clients
  15. Report and document emergency situations according to policy and procedure
  16. Identify and prioritise nursing interventions according to client needs
  17. 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:

 

 

 

 

 

 

 

Use critical thinking and problem solving approaches in undertaking client/s care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Administer medications safely and based on knowledge of principles of drug actions and side effects in accordance with organisation policies and procedures

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 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

  1. Confirm the roles and responsibilities of members of the emergency response team
  2. Prepare and/or check the equipment on the emergency trolley
  3. Access, in response to request from emergency response team, drugs commonly used during emergency resuscitation (including drugs for anaphylaxis)
  4. Participate in performing emergency resuscitation techniques
Confirm the roles and responsibilities of members of the emergency response team

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare and/or check the equipment on the emergency trolley

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access, in response to request from emergency response team, drugs commonly used during emergency resuscitation (including drugs for anaphylaxis)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate in performing emergency resuscitation techniques

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to pre-operative nursing care of a client

  1. Contribute to collection of pre-operative client health assessment data, addressing all relevant factors
  2. Assist in preparation for specific surgical procedures
  3. Contribute to the nursing management of a pre-operative client
  4. Monitor and report on actions and side effects of drugs commonly used pre-operatively
  5. Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures
  6. Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications
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 management of a pre-operative client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor and report on actions and side effects of drugs commonly used pre-operatively

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to post-operative nursing care of a client

  1. Contribute to post-anaesthetic observation of a client following surgery
  2. Apply appropriate post-operative discomfort and pain management strategies as per care plan
  3. Provide nursing management for post-operative clients
  4. Apply knowledge of available drugs commonly used post-operatively for the relief of pain and nausea
  5. Apply appropriate nursing actions to promote client comfort
Contribute to post-anaesthetic observation of a client following surgery

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply appropriate post-operative discomfort and pain management strategies as per care plan

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide nursing management for post-operative clients

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply knowledge 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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to nursing care of the client receiving a blood transfusion

  1. Confirm the rationale for performing a blood transfusion
  2. Contribute to observations of the client undergoing blood transfusion
  3. Work with an awareness of potential complications of blood transfusion
  4. Take appropriate precautions relating to bodily fluids
Confirm the rationale for performing a blood transfusion

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to observations of the client undergoing blood transfusion

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Work with an awareness of potential complications of blood transfusion

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Take appropriate precautions relating to bodily fluids

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

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

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

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

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 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