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

Consistency of performance should be demonstrated over the required range of situations relevant to the work

Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the work context, the assessment environment should represent work conditions as closely as possible

Resource implications

Assessment requires access to:

appropriate equipment

relevant clinical guidelines and organisation policies and procedures

working inpatient facility

inpatients

Consistency in performance

Competency should be demonstrated over time with a range of inpatient care situations that could be expected in the workplace

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 may be assessed independently, but holistic assessment with other clinical units is encouraged

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:

Cultures relevant to the particular service or organisation

Human anatomy and physiology

Legislation and common law pertinent to nursing practice

Inpatient process including:

inpatient assessment

inpatient diagnosis

planning inpatient care

implementing inpatient care including therapeutic interventions

reviewing inpatient care

Organisation policies and procedures pertinent to nursing practice

Pathophysiology and aetiology of disease

Pathophysiology and disease processes

Role of other health care providers and support services

Essential skills:

It is critical that the candidate demonstrate the ability to:

Work as a member of an inpatient care team in order to meet the needs of the client

Communicate effectively with client and other stakeholders

In addition, the candidate must be able 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:

Admit and discharge a client into and from an inpatient care facility

Analyse and interpret clinical information in order to formulate a nursing diagnosis

Complete basic arithmetic calculations

Conduct an inpatient assessment including:

conducting an inpatient physical examination

facilitating diagnostic testing

obtaining and recording a nursing history

Contribute to planning inpatient care including:

discharge plan

expected outcomes

inpatient care goals

inpatient care priorities

therapeutic interventions

Coordinate activities to meet the needs of the inpatient care plan

Evaluate inpatient care including:

measuring inpatient progress against goals and expected outcomes

modifying discharge plan

reviewing goals, expected outcomes and therapeutic interventions

reviewing nursing diagnosis

Implement inpatient care in accordance with the inpatient care plan

Monitor the effectiveness of therapeutic interventions

Prioritise workload·

Read and interpret health records and other data relevant to the client's health status Solving problem skills

Record clinical information regarding inpatient care in a manner so it may be easily interpreted by others

Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues

Use available resources

Use communication and negotiation skills

Work with others and display empathy with clients and relatives

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.

Inpatient care may include:

Applying occupational health and safety policies

Applying personal hygiene and infection control policy and procedures

Communicating effectively with clients and significant others

Dealing with conflict and challenging situations in a thoughtful and appropriate manner

Maintaining client confidentiality

Meeting duty of care

Performing therapeutic interventions

Providing first aid and responding to emergency situations

Providing specific and appropriate information to clients and significant others

Participating in client handover activities, ward rounds to insure continuity of care

Supporting client administration

Working effectively with others in the workplace in a team situation

Activities of daily living include:

Breathing

Communicating

Controlling body temperature

Dying

Eating and drinking

Eliminating waste

Expressing sexuality

Maintaining a safe environment

Mobilising

Personal cleansing and dressing

Sleeping

Working and playing

Clinical guidelines, codes and organisation policies and procedures may include:

ADF Nursing policy and procedure manuals

Clinical standards

Codes of ethics

Codes of practice

Industry professional bodies standards

Industry standards (state and national)

Organisation health policy directives

Relevant Australian standards

Relevant Commonwealth Acts

Standards for nursing practice

Standards for client care

Admitting the client may include:

Advising staff of the client's arrival

Allocating and preparing bed and room

Checking client identity with details on admission referral

Explaining the admission procedure to the client

Organising client belongings and valuables

Orientating the client to the facility

Preparing inpatient documentation

Welcoming and establishing a rapport with client and significant others

Assessment of the inpatient includes:

Obtaining subjective and objective relevant clinical data

Clinical data gathered from:

nursing history

physical examination

diagnostic testing

validating gathered data

Personal hygiene and infection control procedures may include:

Australian and state standards and legislation

Industry standards

Organisation procedures

Standard precautions such as hand washing procedures

Direct instructions from supervisor

Preparing an inpatient assessment may include:

Assessing the environment for suitability to conduct an inpatient assessment

Selecting and assembling equipment and supplies

Checking and calibrating equipment ready for use

Accessible information, including required forms

Explained the assessment procedure clearly and simply to the client in order to clarify its purpose and structure

Gaining informed consent from the client where applicable

Given the client the opportunity to ask questions and discuss concerns

Assuring and maintaining confidentiality of client information

Using personal protective equipment as required

Client history may include:

Biographical information:

gender

name

personal identification number

date of birth

address

occupation

marital status

next of kin

Physical information:

perception of health status

past health problems and therapies

present health therapies

risk factors

activity and coordination

review of systems

developmental stage

effect of health status on developmental stage

ability to complete activities of daily living

Emotional information:

behavioural and emotional status

support systems

self concept

body image

mood

sexuality

coping mechanisms

Social information:

financial status

recreational activities

primary language

cultural influences

environmental risk factors

social relationships

Intellectual information:

intellectual performance

problem solving ability

educational level

communication patterns

attention spans

long-term and recent memory

Spiritual information:

beliefs and meaning

religious experiences

rituals and practices

Physical examination may include:

Appropriate manoeuvres

Auscultation

Inspection

Palpation

Percussion

Relevant clinical measurements

Relevant vital signs

An inpatient diagnosis may include:

Diagnostic label (the problem e.g. constipation)

Related factors (the cause e.g. inadequate dietary fibre)

Inpatient care goals may be:

Allocated against each diagnosis

Expressed in behavioural terms

Short term or long term

Observable and measurable

Outcomes or results which are expected as a consequence of inpatient care

Realistic and attainable

Inpatient care expected outcomes are:

A measurable change of a client's health status in response to inpatient care

A projected time span for goal attainment and an opportunity to state additional resources which may be required in the care plan

Guideposts to determine when specific client centred goals have been met

Observable client behaviour and measurable criteria for inpatient care goals

Used as criteria to evaluate the effectiveness of nursing activities

A desired response of a client's condition in the following dimensions:

physical

social

emotional

developmental

spiritual

Establishing inpatient care priorities includes:

Balancing the client care priorities of:

physiological needs

sociocultural needs

psychological needs

Ranking the diagnosis in order of importance based on client's:

health desires

physiological needs

safety

Prioritising inpatient care into:

high priority needs

intermediate priority needs

low priority needs

Therapeutic interventions includes activities to meet the following:

Blood circulation needs

Comfort, rest and sleep needs

Elimination needs

Fluid and electrolyte needs

Hygiene needs

Movement and exercise needs

Nutritional needs

Oxygen needs

Psychosocial and communication needs

Safety and protection needs

Temperature regulation needs

The needs of the dying

Special needs may include:

Appropriate staff ratios/training/expertises

Cultural/spiritual/social needs

Individual differences/needs/wants/abilities

Impaired communication skills and techniques

Isolation or barrier nursing needs

Mobility and immobility needs

Sensory alterations

Specific equipment/apparatus requirements

Skin integrity and wound care needs

Surgical/rehabilitative/palliative needs

Clinical pathway may include:

Guide to best practice management for all clinical staff associated with the care of the client

Multidisciplinary treatment plan

Pre-determined type of intervention against a desired outcome

Sequenced therapeutic intervention over a projected time frame for a specific nursing diagnosis

Discharge plan may include:

Estimating the client's functional potential (activities of daily living) and planning with this in mind

Involving the client and significant others in planning the discharge

Organising referral to the appropriate health care agency or family who will assist the client with continuing care

Planning for care in another setting including access to support services

Planning to maintain continuity of care including access to specialist equipment and resources

Pre-discharge client education

Providing adequate notice to client and significant others

Providing the client information about their treatment and condition

Planning with the client ways and methods to overcome potential problems that may arise post discharge

Significant others may include:

Client's direct or indirect family members

Client's friends or close associates

Client's work colleagues