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Evidence Guide: HLTEN606B - Assess clients and manage client 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

 

HLTEN606B - Assess clients and manage client care

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

Determine the health status and nursing needs of client(s) in consultation/ collaboration with a registered nurse

  1. Undertake holistic assessment of a client/group of clients in consultation/collaboration with a registered nurse
  2. Use a range of assessment tools relevant to the clinical environment to gather information
  3. Assess the client's current knowledge and understanding of their condition, management and treatment therapies
  4. Review, where relevant, the significant other's knowledge of the client's condition management and treatment therapies
  5. Assess, where appropriate, the response of significant others to the client's current condition
  6. Discuss assessment data with the registered nurse, and other members of the health care team as required to support best practice in nursing care delivery
  7. Clearly and accurately explain the pathophysiology of the presenting complaint experienced by the client to support client understanding
  8. Identify health promotion and client education needs
Undertake holistic assessment of a client/group of clients in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use a range of assessment tools relevant to the clinical environment to gather information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess the client's current knowledge and understanding of their condition, management and treatment therapies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review, where relevant, the significant other's knowledge of the client's condition management and treatment therapies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess, where appropriate, the response of significant others to the client's current condition

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss assessment data with the registered nurse, and other members of the health care team as required to support best practice in nursing care delivery

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Clearly and accurately explain the pathophysiology of the presenting complaint experienced by the client to support client understanding

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify health promotion and client education needs

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate in management of the plan of care for client/group of clients

  1. Analyse client information to reflect individualised care requirements in accordance with health unit policy
  2. Formulate a care plan utilising research-based practice to reflect individual case-management in consultation/collaboration with a registered nurse
  3. Demonstrate an understanding of risk management principles in planning care for client
  4. Identify health promotion and client education needs within the care plan
  5. Discuss the care plan with the registered nurse and other members of the health care team to ensure common understanding for implementation
  6. Following client consent, discuss the care plan with significant other(s)
  7. Commence discharge planning in accordance with health unit policy
  8. Manage the care of clients including the delegation of aspects of nursing work following consultation/ collaboration with the registered nurse and the clinical supervision of others providing aspects of nursing work
Analyse client information to reflect individualised care requirements in accordance with health unit policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Formulate a care plan utilising research-based practice to reflect individual case-management in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Demonstrate an understanding of risk management principles in planning care for client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify health promotion and client education needs within the care plan

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss the care plan with the registered nurse and other members of the health care team to ensure common understanding for implementation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Following client consent, discuss the care plan with significant other(s)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Commence discharge planning in accordance with health unit policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Manage the care of clients including the delegation of aspects of nursing work following consultation/ collaboration with the registered nurse and the clinical supervision of others providing aspects of nursing work

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to the multidisciplinary approach to health care

  1. Liaise with service providers and utilise appropriate resources in providing care to client(s)
  2. Liaise with registered nurses and other members of the health care team about alterations in conditions of client(s)
  3. Assist client(s) in discharge preparation on commencement of treatment/care and assessment of individual needs in consultation/collaboration with a registered nurse
  4. Manage ongoing education and support for client(s) and significant others where appropriate
  5. Provide comprehensive hand-over to nurses on other shifts
Liaise with service providers and utilise appropriate resources in providing care to client(s)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Liaise with registered nurses and other members of the health care team about alterations in conditions of client(s)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist client(s) in discharge preparation on commencement of treatment/care and assessment of individual needs in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Manage ongoing education and support for client(s) and significant others where appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide comprehensive hand-over to nurses on other shifts

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement best practice nursing interventions for client/s in consultation/ collaboration with a registered nurse

  1. Prioritise and manage nursing interventions for client(s) according to the individual's needs and re-prioritise as required to address changes in nursing workload in consultation/collaboration with a registered nurse
  2. Modify nursing interventions to reflect changes in the client's condition in consultation/collaboration with a registered nurse
  3. Perform nursing interventions, including the use of complex client monitoring devices utilising research-based evidence
  4. Perform nursing interventions within professional, legal, ethical and organisation policy and procedure guidelines/boundaries in consultation/ collaboration with a registered nurse
  5. Recognise alterations in psychological and/or physiological status promptly, manage and report to appropriate health care staff
  6. Administer medications safely, based on knowledge of principles of drug actions and side effects, in accordance with health unit policies and procedures and legislation
  7. Promote partnership between nurse and client in the implementation of health promotion and self management in relation to research-based evidence
  8. Consistently maintain occupational health, safety and welfare policies and procedures relating to nursing practice
Prioritise and manage nursing interventions for client(s) according to the individual's needs and re-prioritise as required to address changes in nursing workload in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Modify nursing interventions to reflect changes in the client's condition in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform nursing interventions, including the use of complex client monitoring devices utilising research-based evidence

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform nursing interventions within professional, legal, ethical and organisation policy and procedure guidelines/boundaries in consultation/ collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Recognise alterations in psychological and/or physiological status promptly, manage and report to appropriate health care staff

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Administer medications safely, based on knowledge of principles of drug actions and side effects, in accordance with health unit policies and procedures and legislation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Promote partnership between nurse and client in the implementation of health promotion and self management in relation to research-based evidence

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consistently maintain occupational health, safety and welfare policies and procedures relating to nursing practice

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate client responses to nursing interventions in consultation/collaboration with a registered nurse

  1. Evaluate each client's response to nursing interventions and modify interventions accordingly in consultation/collaboration with a registered nurse, and in line with organisation policies/procedures and research-based evidence
  2. Evaluate each client's response to health promotion/education and address issues accordingly in consultation/collaboration with a registered nurse, and in line with organisation policies/procedures and research-based evidence
  3. Undertake assessment of the clients' progress toward planned outcomes in relation to nursing care provided in consultation/collaboration with a registered nurse
  4. Document all aspects of evaluation in line with organisation policies/procedures
Evaluate each client's response to nursing interventions and modify interventions accordingly in consultation/collaboration with a registered nurse, and in line with organisation policies/procedures and research-based evidence

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate each client's response to health promotion/education and address issues accordingly in consultation/collaboration with a registered nurse, and in line with organisation policies/procedures and research-based evidence

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Undertake assessment of the clients' progress toward planned outcomes in relation to nursing care provided in consultation/collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document all aspects of evaluation in line with organisation policies/procedures

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

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 the clinical workplace or 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

Access and equity considerations:

Workers should have an understanding of Aboriginal and/or Torres Strait Islander culture and history and an ability to work with Aboriginal and/or Torres Strait Islander clients and communities

Assessors and trainers must have a knowledge of and take into account the influence of cultural and historic factors relating to health for those working with Aboriginal and/or Torres Strait Islander clients and communities

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

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:

Age and gender issues for nursing practice

Contemporary health and illness issues

Cultural and religious considerations for nursing practice

Ethical guidelines including confidentiality, duty of care and public liability

Factors influencing lifestyle choices - personal coping mechanisms, primary health care principles

Factors that affect health

Healthy lifestyle strategies

In-depth understanding of the structure and functioning of anatomy and physiology and pathophysiology of the human body

Knowledge of best practice, philosophy/vision/mission statements

Organisation policies and procedures and protocols

Patterns of nursing care (including functional, team, client assignment and primary nursing)

Risk factors to health

Role of evidence based practice

Social and personal wellbeing

Socio-economic, physiological, emotional and physical variables

Statutory requirements for data collection and documentation in relation to research

Understand the role of the health care team members

Understanding of the scope of practice of the Enrolled/Division 2 nurse at this level and the relationship with the registered nurse

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 interpersonal skills, including working with others, using sensitivity when dealing with people and relating to persons from differing cultural, social and religious backgrounds

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 clinical nursing skills including:

assessment of physical reflexes

assessment, observation and documentation of:

body Mass Index

glucose monitoring

height and weight

hydration

neurovascular observations

nutritional status

oxygen saturation

pain scale or analogue observations

respiratory function

chest pain assessment&management

complex nursing interventions

cough CPR and pre-cordial thump

emergency medications

fundamental nursing interventions

medication administration

neurological function

physical assessment skills

specimen collection

Apply additional clinical nursing skills appropriate to role, including:

12 lead ECG, monitoring of invasive equipment and readings

Arterial line Management

Central Venous Catheter Management

CPAP and BiPAP (non-invasive)

Modified advanced life support

PICC/Midline Management

Under Water Seal Drain Management

continued ...

Essential skills:

Conduct physical examination of client

Demonstrate a professional approach to health education, knowledge of health systems and disease processes

Demonstrate accountability for personal outputs and broad client group outcomes

Use appropriate communication skills(non-verbal, openness, sensitivity, non-judgemental attitudes)

Use oral communication skills (language competence) required to fulfil job roles as specified by the organisation/service. Oral communication skills include interviewing techniques, asking questions, active listening, asking for clarification

Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation/service. The level of skill may range from reading and understanding client documentation to completion of written reports

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.

Clients may include:

Child

Adolescent

Adult and Older adult

Acutely or Chronically ill client

Respite client

Complex client monitoring devices

Respirators

ECG machines

Health care settings may include:

Aged care and Respite centres

Short and long stay centre

Community setting

Medical clinic

Hospitals

Client based information includes:

Demographic data:

name

next of kin/significant others

known allergies

Religious and cultural practices and beliefs

Psychosocial needs

Previous medical and surgical history

Medications

Performance of activities of daily living and deficits to performing activities of daily living

Preliminary health assessment

Understanding of client needs including:

cultural, age and gender specific

stage of development

physical, emotional, psychosocial, health problem specific

Client based observations may include:

Temperature, pulse, respirations, blood pressure

Urinalysis

Height and weight, Body Mass Index

Oximetry and oxygen saturation

Specimen collection

Neurological observations

Neurovascular observations

Blood glucose monitoring

Pain scale or analogue observations

12 lead ECG, monitoring of invasive equipment and readings.