ELEMENT

PERFORMANCE CRITERIA

1. Collect data that contributes to client health care plan

1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions

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

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

1.4 Record lifestyle patterns and coping mechanisms in documentation

1.5 Document current client health practices, issues and needs

1.6 Document gender, age, cultural, religious and/or spiritual data in preliminary health assessment

1.7 Identify the likely impact of specific health care on the client's health

1.8 Involve client in the process of data collection wherever possible

1.9 Access client information from appropriate family member or carer (if client is unable)

1.10 Identify the emotional and physical needs of family and significant others in supporting the client

1.11 Document and report variations from normal on a regular basis

1.12 Validate extraordinary findings immediately, document and report abnormalities to the registered nurse

1.13 Undertake ongoing client assessment

2. Undertake client assessment for admission and discharge

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

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

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

2.4 Follow organisation policies and procedures relating to client participation

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

2.6 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

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

2.8 Accurately record and report admission and discharge information

3. Analyse client health assessment data and observations

3.1 Accurately interpret information gained from health assessments and observations as being within normal range and/or refer to appropriate health care colleague for interpretation

3.2 Report change in client health status in a timely manner to the appropriate health care colleague

3.3 Identify the likely cause of any significant variation(s) from normal in relation to providing care

3.4 Reflect consideration for age and developmental state of client in performance of clinical nursing assessment

3.5 Analyse physiological aspects of human growth and its impact on client health

3.6 Reflect the client's interests, physical, emotional and psychosocial needs in documentation

3.7 Respect cultural, spiritual and religious wishes during nursing assessment

3.8 Use client health history as part of planning care in line with health organisation requirements

4. Contribute to the development of individual care plans for clients

4.1 Conduct a holistic health assessment reflecting the nursing philosophy or theory of the organisation in consultation/collaboration with a registered nurse

4.2 Use appropriate health assessment tools and appropriate terminology in documentation as well as a variety of sources and clinical situations

4.3 Use a problem solving approach in the development of care plans for clients

4.4 Discuss care requirements with the client and/or their family or significant other to ensure information is accurate

4.5 Verify client based information to ensure client's uniqueness and individuality is reflected in the care plan

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

4.7 Record age and gender issues in the development of individualised care plans

4.8 Incorporate cultural, spiritual and religious beliefs in the development of individualised care plans

4.9 Ensure documentation reflect the client's needs: physical, emotional, spiritual and psychosocial

4.10 Ensure nursing care plan addresses principles of best practice and risk assessment and identifies stress management techniques for clients

5. Prepare for client discharge

5.1 Identify appropriate community support services to the client

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

5.3 Ensure client has all requirements for discharge: next GP's appointment; medications; and any referrals

5.4 Ensure documentation is completed as per policy and procedure