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Evidence Guide: HLTENN004 - Implement, monitor and evaluate nursing care plans

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

 

HLTENN004 - Implement, monitor and evaluate nursing care plans

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

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare a person for care procedures.

  1. Explain the procedures, preparation required and timeframe involved and gain the person’s consent.
  2. Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.
Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement care procedures to meet identified needs.

  1. Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.
  2. Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.
  3. Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.
  4. Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.
  5. Use appropriate measures to promote the person’s comfort, rest and sleep.
  6. Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.
  7. Identify and respond appropriately to signs and symptoms of an emergency situation or condition.
Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use appropriate measures to promote the person’s comfort, rest and sleep.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor a person’s identified care needs.

  1. Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.
  2. Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.
  3. Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.
Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate outcomes of care provided.

  1. Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.
  2. Evaluate the person’s progress towards planned outcomes as documented in the care plan.
  3. Make required changes to nursing care plan in line with best practice in nursing.
  4. Record and report all aspects of the evaluation of nursing care provided.
Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate the person’s progress towards planned outcomes as documented in the care plan.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make required changes to nursing care plan in line with best practice in nursing.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record and report all aspects of the evaluation of nursing care provided.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor a person’s identified care needs.

  1. Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.
  2. Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.
  3. Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.
Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

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. Prepare a person for care procedures.

1.1 Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

1.2 Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

2. Implement care procedures to meet identified needs.

2.1 Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

2.2 Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

2.3 Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

2.4 Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

2.5 Use appropriate measures to promote the person’s comfort, rest and sleep.

2.6 Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

2.7 Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

2.8 Use emergency codes correctly and initiate basic life support according to organisation policy and procedures.

3. Monitor a person’s identified care needs.

3.1 Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

3.2 Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

3.3 Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

4. Evaluate outcomes of care provided.

4.1 Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

4.2 Evaluate the person’s progress towards planned outcomes as documented in the care plan.

4.3 Make required changes to nursing care plan in line with best practice in nursing.

4.4 Record and report all aspects of the evaluation of nursing care provided.

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. Prepare a person for care procedures.

1.1 Explain the procedures, preparation required and timeframe involved and gain the person’s consent.

1.2 Maintain the person’s privacy and dignity and use a culturally appropriate approach during preparation and procedures.

2. Implement care procedures to meet identified needs.

2.1 Assist the person to address their personal and oral hygiene and their dressing and grooming needs in achieving health outcomes.

2.2 Identify contributing factors and implement appropriate strategies to prevent and manage skin breakdown.

2.3 Confirm the person’s nutritional and elimination needs and apply strategies to meet identified needs.

2.4 Assist the person’s respiratory function by demonstrating and promoting deep breathing and coughing exercises.

2.5 Use appropriate measures to promote the person’s comfort, rest and sleep.

2.6 Actively encourage the person to contribute to their own independence and mobility through active and passive exercises.

2.7 Identify and respond appropriately to signs and symptoms of an emergency situation or condition.

2.8 Use emergency codes correctly and initiate basic life support according to organisation policy and procedures.

3. Monitor a person’s identified care needs.

3.1 Maintain ongoing assessment of the person through observation and by using monitoring equipment and devices.

3.2 Prioritise work activities to address the person’s urgent needs, maintaining a balanced approach to own workload.

3.3 Record and report concerns in the person’s condition or behaviour to the registered nurse, and report situations of risk according to organisation policy and procedures.

4. Evaluate outcomes of care provided.

4.1 Consult and collaborate with interdisciplinary team to identify and evaluate own contributions to the person’s care.

4.2 Evaluate the person’s progress towards planned outcomes as documented in the care plan.

4.3 Make required changes to nursing care plan in line with best practice in nursing.

4.4 Record and report all aspects of the evaluation of nursing care provided.

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 work in in accordance with Nursing and Midwifery Board of Australia professional standards of practice, codes and guidelines

implemented and monitored at least 2 different nursing care plans in the workplace

evaluated at least 1 nursing care plan in the workplace or in a simulated environment

used emergency codes and performed basic life support in a simulated environment on an adult, child and infant manikin according to organisation policy and procedures.

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:

activities of daily living

factors that promote and impede comfort, sleep and rest

purpose of hygiene and grooming

actual and potential nursing care including:

hygiene and toileting

elimination needs, including procedures used to assist with elimination

incontinence management, including aids or devices

physical comfort

sleep disturbances

oral hygiene including:

teeth brushing

care of dentures

using alcohol-free mouthwash

interdental cleaning

immobility

respiration and circulation

fluid and nutritional deficits

pain

underlying medical condition

sensory deficits, including use of personal aids and devices

cognitive deficits

basic life support including:

how to perform cardiopulmonary resuscitation (CPR)

use of and response to emergency codes

considerations when providing basic life support including

airway obstruction due to body position

appropriate duration and cessation of CPR

appropriate use of an Automatic External Defibrillator (AED)

risk identification related to episodic care:

age

anaesthesia and surgery

cognitive status

deep vein thrombosis, venous thromboembolism, pulmonary embolism

immobility

length of stay

mental health condition

non-compliance

nutritional status

pain

presence of morbidity

risk prevention strategies including:

maintaining a safe environment

preventing falls and falls assessment

promoting active and passive exercises

promoting deep breathing and coughing exercises

maintaining skin integrity and pressure area care

recording and reporting requirements for comprehensive clinical handovers and case meetings.