Application
The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurses and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements |
Prerequisites
Not Applicable
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
1. Identify the impact of acute health problems on the client and their family. | 1.1 Identify the clinical manifestations of presenting acute health problem(s) 1.2 Identify actual and potential health issues of a client presenting with an acute health problem through discussion of information gained from a preliminary health assessment with the appropriate members of the health care team 1.3 Use a problem solving approach to assess the impact of the acute health problem on the client and their family and the achievement of activities of daily living 1.4 Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client 1.5 Maintain confidentiality in line with facility policy and procedures |
2. Contribute to planning care for the client with acute health problems | 2.1 Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy 2.2 Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy 2.3 Accurately gather, document and report changes in client condition to appropriate health care team members 2.4 Document information gathered from client and family to assist in development of the care plan 2.5 Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan 2.6 Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team 2.7 Implement client discharge procedure in line with organisation policy and procedures 2.8 Advocate for clients in health and/or community settings |
3. Perform nursing interventions to support health care of clients with acute health problems | 3.1 Undertake nursing interventions based on predetermined plans of care 3.2 Ensure nursing interventions reflect client needs and individuality 3.3 Perform nursing interventions with respect for the dignity of the client 3.4 Reflect consideration of cultural and religious issues in the performance of nursing interventions 3.5 Encourage the client and/or their significant others to assist in the performance of nursing interventions if able 3.6 Consider physical, psychological and social needs in the performance of nursing interventions 3.7 Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements 3.8 Assist clients to meet their activities of daily living 3.9 Address gender and age issues in the performance of nursing interventions 3.10 Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements 3.11 Contribute to and support health teaching plans for the client with an acute health problem 3.12 Identify appropriate psychological support and care for individual clients 3.13 Report and document emergency situations according to policy and procedure 3.14 Identify and prioritise own nursing interventions according to client needs 3.15 Reflect pre- and post-procedure care in nursing interventions |
4. Contribute to an emergency response | 4.1 Confirm the roles and responsibilities of members of the emergency response team 4.2 Participate in performing emergency resuscitation techniques |
5. Contribute to pre-operative nursing care of a client | 5.1 Contribute to collection of pre-operative client health assessment data, addressing all relevant factors 5.2 Assist in preparation for specific surgical procedures 5.3 Contribute to the nursing care of a pre-operative client 5.4 Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications 5.5 Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor |
6. Contribute to post-operative nursing care of a client | 6.1 Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse 6.2 Accurately gather, document and report changes in client condition to appropriate health care team member 6.3 Provide nursing care for post-operative clients 6.4 Contribute to observations of the client undergoing blood transfusion 6.5 Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea 6.6 Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse 6.7 Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures 6.8 Ensure client is attending to post operative exercises |
Required Skills
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: Activities of daily living Acute care nursing interventions and outcomes Acute rehabilitation strategies and techniques Admission and discharge processes Anatomy and physiology Application of nursing theory Awareness and understanding of potential post operative complications Clinical manifestations of acute disease states/illnesses Concepts of homeostasis Documentation principles Effective communication skills/Medical terminology, including common terminology associated with surgery Emergency care and first aid procedures Emergency management protocols for cardiac and/or respiratory arrest Equipment used in acute care environments Ethical guidelines including confidentiality, duty of care and public liability Fundamental nursing interventions Legal requirements for practice Members of health care team Organisation policy and procedures, guidelines and protocols Pre and post operative nursing management Principles of surgical nursing Surgical procedures and related terminology Workplace health and safety legislation Workplace Health and Safety legislation |
Essential skills: It is critical that the candidate demonstrate the ability 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: Apply professional standards of practice: ANMC code of conduct ANMC code of ethics ANMC national Enrolled/Division 2 nurse competency standards state/territory Nurse Regulatory Nurses Act state/territory Nursing and Midwifery Regulatory Authority standards of practice scope of nursing practice decision making framework Apply problem solving skills, including use of tools and techniques to solve problems, analyse information and make decisions that require discretion and confidentiality Perform acute clinical nursing interventions/procedures specific to acute client care client history/assessment discharge planning pre-operative preparation post-operative care health education observations check vital signs - respiratory status, profusion status, urinalysis, blood sugar level, temperature status, oxygen saturation and pain tolerance assessment Participate as a member of a health care team Use interpersonal skills including working with others, empathising with clients, family and colleagues, using sensitivity when dealing with people and relating to persons from differing cultural, spiritual, social and religious backgrounds Use advanced oral communication skills (language competence) required to fulfil job roles as specified by the organisation/service, including: interviewing techniques asking questions active listening asking for clarification from consumer or other persons where appropriate negotiating solutions acknowledging and responding to a range of views Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation/service using a level of skill ranging from reading and understanding client reports and documentation to completion of written reports |
Evidence Required
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 assignments/projects Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Questioning - verbal or written Role play Simulation/virtual 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 and/or Torres Strait Islander clients and communities |
Related units: | This unit is recommended to be assessed in conjunction with the following related competency unit: 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 |
Sectors
Not Applicable
Employability Skills
This unit contains Employability Skills |
Licensing Information
Not Applicable