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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 Observation of performance in a work context is essential for assessment of this unit Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse

Context of and specific resources for assessment	This unit is most appropriately assessed in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the workplace Where for reasons of safety access to equipment and resources and space assessment takes place away from the workplace simulations should be used to represent workplace conditions as closely as possible

Method of assessment	Observation in the workplace Written assignmentsprojects Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Questioning verbal or written Role play Simulationvirtual clinical setting laboratory to accommodate learning

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 andor Torres Strait Islander clients and communities

Related units	This unit is recommended to be assessed in conjunction with the following related competency unit HLTAPB Confirm physical health status HLTAP401B Confirm physical health status

Range Statement



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.

Health care settings may include:	Hospitals Residential aged care facilities Respite centres Short/long stay centres Community setting Rural and remote settings

Plans of care could include:	Nursing care plans Clinical pathways Treatment plans Medical notes Client notes Manual and electronic storage systems Resident classification records

Acute health problems may include the following:	Acute renal disorders Acute abdomen Acute neurological disorder Acute pain Acute respiratory disorders Acute unconscious state Angina Burns Cellulitis Deep Vein thrombosis Dehydration Elective/emergency surgery (post operative phase) Fractures Haemorrhage Head injury Myocardial infarction Renal calculi Sepsis Shock Tropical diseases Wounds
Acute clinical nursing interventions could include:	Assist achievement of activities of daily living Acute admission procedure Acute wound management Airway management Application of anti embolism stockings Observation and reporting of acute pain Assessment/observation of level of consciousness Assessment/observation of respiratory function Complications of acute bed rest Discharge of client First aid Fluid balance recording Incentive spirometry and peak flow measurements Neurovascular observations Pre operative observations, exercises and care Post operative observations, exercises and care Preparation for medical procedure Preparation for surgical procedure Pulse oximetry Tracheostomy care (established stoma) Transfer of client - intra-facility Transfer/evacuation of client to another facility

Common terminology associated with surgery may include:	Elective/emergency General/local/epidural/spinal anaesthetic Caudal/peripheral nerve block Debridement Skin graft Amputation Open reduction Hip replacement Craniotomy Tonsillectomy Appendicectomy Laparotomy Hysterectomy Prostatectomy Cataract extraction Haemorrhage Deep vein thrombosis

When communicating/caring for a client, the following may need to be considered:	Any physical or mental problems which may hinder communication (such as deafness or dementia, or disease processes) Individual consideration of the following socio-economic, physiological variables will be addressed (social, gender, emotional, intellectual, language, culture) All verbal and non-verbal interactions with client and colleagues in a range of appropriate interpersonal context Effective communication skills include non judgemental attitude, active listening and use of culturally appropriate communication methods (verbal and non-verbal) Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines

Observations may include, but are not limited to:	Respiratory status assessment (ie. Rate, rhythm, depth and sound) Cardiovascular status assessment ( ie. Pulse, blood pressure) Temperature status assessment Oxygen saturation (ie. Triflow, peak flow, oxygen therapy) Urinalysis Faecal assessment Blood sugar level

Client history may include:	Pre-existing medical conditions Allergies Current history Diagnostic procedures/investigations Allied health team recommendations Current medication Continence status Skin integrity Mobility Nutritional status Hydration status Psychosocial needs Next of kin Previous surgery

Pre-operative assessment data may include:	Vital signs Allergies Age, height, weight Urinalysis Hydration/nutritional status Medical/surgical history (including family history) Prescribe and non-prescribed medications Patterns of drug use/smoking/alcohol
Specific preparation may include:	Fasting Skin preparation Appropriate dress for surgical procedure Removal of jewellery and safe storage Administration of prescribed pre-medications Denture removal (if necessary) ID band/allergy ID Check documentation is complete, including signed consent Removal of sensory aids eg. hearing aid, glasses if required

Drugs commonly used pre-operatively may include:	Sedatives/hypnotics Anticholinergics Topical analgesia Anti-angina medication Bronchodilators

Post operative pain management strategies may include:	Patient controlled analgesia (PCA) Narcotic infusion Epidural analgesia Topical analgesia Oral analgesics Subcutaneous/intramuscular injection analgesia

Post anaesthetic and post-operative observations may include:	Level of consciousness Vital signs Intravenous therapy Indwelling catheters Neurovascular observations Skin colour Fluid output - urinary, wound drainage, suction, vomitus Indwelling catheter position Urine output

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HLTEN415B - Deliver nursing care to acute care clients

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Elements and Performance Criteria

Required Skills

Evidence Required

Range Statement