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Evidence Guide: HLTENN003 - Perform clinical assessment and contribute to planning nursing care

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

 

HLTENN003 - Perform clinical assessment and contribute to planning nursing care

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

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Collect and interpret health data.

  1. Introduce self and explain processes before commencing nursing assessment activities.
  2. Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.
  3. Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.
  4. Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.
  5. Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.
  6. Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.
  7. Clarify the emotional and physical needs of the family or carer in supporting the person.
  8. Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.
  9. Communicate immediately all deterioration concerns about the person to registered nurse.
Introduce self and explain processes before commencing nursing assessment activities.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Clarify the emotional and physical needs of the family or carer in supporting the person.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Communicate immediately all deterioration concerns about the person to registered nurse.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Undertake admission and discharge procedures for a person.

  1. Collect data from the person for admission and discharge planning as required by organisation policy and procedures.
  2. Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.
  3. Identify community support services and resources to assist in planning for discharge.
  4. Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.
Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify community support services and resources to assist in planning for discharge.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to planning the nursing care of a person.

  1. Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.
  3. Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.
Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to ongoing development of individual nursing care plans.

  1. Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.
  2. Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.
  3. Ensure nursing care plan is based on principles of best practice and risk assessment.
  4. Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.
Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure nursing care plan is based on principles of best practice and risk assessment.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Collect and interpret health data.

1.1 Introduce self and explain processes before commencing nursing assessment activities.

1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

1.7 Clarify the emotional and physical needs of the family or carer in supporting the person.

1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

1.9 Communicate immediately all deterioration concerns about the person to registered nurse.

2. Undertake admission and discharge procedures for a person.

2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

2.3 Identify community support services and resources to assist in planning for discharge.

2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

3. Contribute to planning the nursing care of a person.

3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs.

3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

4. Contribute to ongoing development of individual nursing care plans.

4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

4.3 Ensure nursing care plan is based on principles of best practice and risk assessment.

4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.

Required Skills and Knowledge

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Collect and interpret health data.

1.1 Introduce self and explain processes before commencing nursing assessment activities.

1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

1.7 Clarify the emotional and physical needs of the family or carer in supporting the person.

1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

1.9 Communicate immediately all deterioration concerns about the person to registered nurse.

2. Undertake admission and discharge procedures for a person.

2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

2.3 Identify community support services and resources to assist in planning for discharge.

2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

3. Contribute to planning the nursing care of a person.

3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs.

3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

4. Contribute to ongoing development of individual nursing care plans.

4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

4.3 Ensure nursing care plan is based on principles of best practice and risk assessment.

4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.

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

performed nursing admission and discharge procedures for 2 different people in the workplace as per organisation policy and procedures

conducted holistic clinical health assessment on 2 different people in the workplace or in a simulated environment including:

blood glucose monitoring

oxygen saturation level

body mass index (BMI) or waist hip ratio

integumentary assessment

urinalysis

neurological observations including reflexes

neurovascular observations and assessment of peripheral circulation

pain assessment (including chest pain)

developed at least 1 nursing care plan in the workplace or in a simulated environment based on holistic health assessment undertaken with a real person.

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:

admission and discharge planning processes and documentation required

developmental stages of childhood:

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

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

role of play in a child’s development

impact of hospitalisation on child and family

developmental stages of adolescence and common health issues for adolescents

developmental stages of adulthood and major activities related to each stage

impact of infertility on people

approaches to understanding human growth and development

influences of genetics and environment on development

family health care needs

gender-specific health care needs

how to use equipment for health assessment and data collection

how to assist a person in activities of daily living including identified aids to assist these activities

how to perform clinical measurements and/or assessments for:

blood glucose level

blood pressure

body mass index or waist hip ratio

height and weight

level of consciousness

pupil reaction

neurological reflexes

peripheral circulation

sensory perception and identified personal aids and devices required for hearing or sight

skin colour, integrity and turgor

temperature, pulse, respirations

urinalysis

human growth and development

interpretation and analysis of a person’s health-related information

principles of health assessment

problem solving strategies and techniques for conducting health assessment

how to recognise a deteriorating patient and determine levels of consciousness

how and when to raise issues of concern about a person’s deterioration

resources for the Core Standards for nurses who support people with a disability (NSW Family and Community Services)

Person Centred Health Care Assessments and the Development of Health Care Plans Core Standard for Practitioners

Mealtime Management for Nurses Practice Package

wellness approach to health, including physiology and psychosocial aspects

variations in health needs and activities of daily living across the person’s lifespan.