Provide inpatient care Evidence Guide

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Evidence Guide: HLTDEFHC405B - Provide inpatient care

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

HLTDEFHC405B - Provide inpatient care

What evidence can you provide to prove your understanding of each of the following citeria?

Assess the inpatient

Admit client to the inpatient care facility in accordance with organisation policies and procedures
Prepare for inpatient assessment in accordance with clinical guidelines, codes and organisation policies and procedures
Obtain and record client history in order to gather data to contribute to the inpatient assessment
Follow personal hygiene and infection control procedures
Conduct physical examination in order to gather data to contribute to the inpatient assessment

Admit client to the inpatient care facility in accordance with organisation policies and procedures

Completed
Date:

Teacher:

Evidence:

Prepare for inpatient assessment in accordance with clinical guidelines, codes and organisation policies and procedures

Completed
Date:

Teacher:

Evidence:

Obtain and record client history in order to gather data to contribute to the inpatient assessment

Completed
Date:

Teacher:

Evidence:

Follow personal hygiene and infection control procedures

Completed
Date:

Teacher:

Evidence:

Conduct physical examination in order to gather data to contribute to the inpatient assessment

Completed
Date:

Teacher:

Evidence:

Formulate an inpatient diagnosis

Analyse data gathered during the inpatient assessment in order to recognise abnormal trends for comparison with normal health patterns
Interpret analysed data to establish what information has clinical significance in relation to the client's health status
Organise data of clinical significance into meaningful clusters to focus on correct identification of any health problem(s)
Formulate inpatient diagnosis based on the analysis, interpretation and clustering of clinically significant data and determined health problem(s)

Analyse data gathered during the inpatient assessment in order to recognise abnormal trends for comparison with normal health patterns

Completed
Date:

Teacher:

Evidence:

Interpret analysed data to establish what information has clinical significance in relation to the client's health status

Completed
Date:

Teacher:

Evidence:

Organise data of clinical significance into meaningful clusters to focus on correct identification of any health problem(s)

Completed
Date:

Teacher:

Evidence:

Formulate inpatient diagnosis based on the analysis, interpretation and clustering of clinically significant data and determined health problem(s)

Completed
Date:

Teacher:

Evidence:

Formulate the inpatient care plan

Establish inpatient care goals to determine the objectives for the inpatient care plan
Establish expected outcomes of inpatient care to measure the progress of the inpatient care plan
Establish priorities for inpatient care to anticipate and sequence therapeutic interventions
Determine therapeutic interventions considering activities of daily living, care priorities and expected outcomes
Integrate special needs of the client into the inpatient care plan
Use relevant clinical pathways in the inpatient care plan
Determine discharge plan considering expected outcomes, support systems and ability to meet activities of daily living
Obtain authorisation of inpatient care plan by clinical supervisor

Establish inpatient care goals to determine the objectives for the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Establish expected outcomes of inpatient care to measure the progress of the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Establish priorities for inpatient care to anticipate and sequence therapeutic interventions

Completed
Date:

Teacher:

Evidence:

Determine therapeutic interventions considering activities of daily living, care priorities and expected outcomes

Completed
Date:

Teacher:

Evidence:

Integrate special needs of the client into the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Use relevant clinical pathways in the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Determine discharge plan considering expected outcomes, support systems and ability to meet activities of daily living

Completed
Date:

Teacher:

Evidence:

Obtain authorisation of inpatient care plan by clinical supervisor

Completed
Date:

Teacher:

Evidence:

Implement inpatient care

Coordinate activities of the client, health care providers and significant others in order to implement the inpatient care plan
Implement care in accordance with the inpatient care plan, therapeutic interventions, clinical guidelines, codes and organisation policies and procedures
Monitor and record client response to inpatient care in accordance with organisation policies and procedures
Report inpatient response other than expected outcomes to clinical supervisor

Coordinate activities of the client, health care providers and significant others in order to implement the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Implement care in accordance with the inpatient care plan, therapeutic interventions, clinical guidelines, codes and organisation policies and procedures

Completed
Date:

Teacher:

Evidence:

Monitor and record client response to inpatient care in accordance with organisation policies and procedures

Completed
Date:

Teacher:

Evidence:

Report inpatient response other than expected outcomes to clinical supervisor

Completed
Date:

Teacher:

Evidence:

Evaluate inpatient care

Measure therapeutic interventions against the goals and expected outcomes in order to amend the inpatient care plan
Measure inpatient progress against goals and expected outcomes of the inpatient care plan
Amend inpatient diagnosis based on inpatient progress and response to therapeutic interventions
Reformulate inpatient care plan based on amended inpatient diagnosis

Measure therapeutic interventions against the goals and expected outcomes in order to amend the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Measure inpatient progress against goals and expected outcomes of the inpatient care plan

Completed
Date:

Teacher:

Evidence:

Amend inpatient diagnosis based on inpatient progress and response to therapeutic interventions

Completed
Date:

Teacher:

Evidence:

Reformulate inpatient care plan based on amended inpatient diagnosis

Completed
Date:

Teacher:

Evidence:

Assessed

Teacher: ___________________________ Date: _

Signature: ________________________________________________

Comments:

Instructions to Assessors

Evidence Guide



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

Required Skills and Knowledge

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

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.

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

NTISthis.com

Evidence Guide: HLTDEFHC405B - Provide inpatient care

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

HLTDEFHC405B - Provide inpatient care

Assess the inpatient

Formulate an inpatient diagnosis

Formulate the inpatient care plan

Implement inpatient care

Evaluate inpatient care

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

Instructions to Assessors

Teacher: ___________________________ Date: _