Course Title: Assess clients and manage client care

National Element Code & Title:

HLTEN606B Assess clients and manage client care

Performance Criteria:

1.1 Undertake holistic assessment of a client/group of clients in consultation/collaboration with a registered nurse
1.2 Use a range of assessment tools relevant to the clinical environment to gather information
1.3 Assess the client's current knowledge and understanding of their condition, management and treatment therapies
1.4 Review, where relevant, the significant other's knowledge of the client's condition management and treatment therapies
1.5 Assess, where appropriate, the response of significant others to the client's current condition
1.6 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
1.7 Clearly and accurately explain the pathophysiology of the presenting complaint experienced by the client to support client understanding
1.8 Identify health promotion and client education needs

Performance Criteria:

2.1 Analyse client information to reflect individualised care requirements in accordance with health unit policy
2.2 Formulate a care plan utilising research-based practice to reflect individual case-management in consultation/collaboration with a registered nurse
2.3 Demonstrate an understanding of risk management principles in planning care for client
2.4 Identify health promotion and client education needs within the care plan
2.5 Discuss the care plan with the registered nurse and other members of the health care team to ensure common understanding for implementation
2.6 Following client consent, discuss the care plan with significant other(s)
2.7 Commence discharge planning in accordance with health unit policy
2.8 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

Performance Criteria:

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

Performance Criteria:

4.1 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
4.2 Modify nursing interventions to reflect changes in the client's condition in consultation/collaboration with a registered nurse
4.3 Perform nursing interventions, including the use of complex client monitoring devices utilising research-based evidence
4.4 Perform nursing interventions within professional, legal, ethical and organisation policy and procedure guidelines/boundaries in consultation/ collaboration with a registered nurse
4.5 Recognise alterations in psychological and/or physiological status promptly, manage and report to appropriate health care staff
4.6 Administer medications safely, based on knowledge of principles of drug actions and side effects, in accordance with health unit policies and procedures and legislation
4.7 Promote partnership between nurse and client in the implementation of health promotion and self management in relation to research-based evidence
4.8 Consistently maintain occupational health, safety and welfare policies and procedures relating to nursing practice
 

Performance Criteria:

5.1 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
5.2 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
5.3 Undertake assessment of the clients' progress toward planned outcomes in relation to nursing care provided in consultation/collaboration with a registered nurse
5.4 Document all aspects of evaluation in line with organisation policies/procedures

Kozier and Erbs ‘ Fundamentals of Nursing’. (2010). 1st edition. Pearson: Australia.
•Tollefson,J. (2010). Clinical psychomotor skills: assessment tools for nursing students. (4th edition). South Melbourne: Cengage Learning.