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.