Course Title: Perform clinical assessment and contribute to planning nursing care

Part A: Course Overview

Program: C5365 Diploma of Nursing

Course Title: Perform clinical assessment and contribute to planning nursing care

Portfolio: SEH Portfolio Office

Nominal Hours: 50

Regardless of the mode of delivery, represent a guide to the relative teaching time and student effort required to successfully achieve a particular competency/module. This may include not only scheduled classes or workplace visits but also the amount of effort required to undertake, evaluate and complete all assessment requirements, including any non-classroom activities.

Course Contact: Leeanne Mond

Course Contact Phone: +61 3 99254837

Course Contact Email: leeanne.mond@rmit.edu.au



Course Description

 

This course of competency describes the skills and knowledge required, within the scope of practice, to perform preliminary and ongoing physical health assessments of all body systems, gathering data that contributes to a person’s individualised health care plan.

 

This course applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.

 

This course includes a Work Integrated Learning experience in which your knowledge and skills will be applied and assessed in a real or simulated workplace context and where feedback from industry and/or community is integral to your experience.


This course includes clinical placement

Pre-requisite Courses and Assumed Knowledge and Capabilities

There are no pre-requisites for this unit of competency



National Competency Codes and Titles

National Element Code & Title:

HLTENN003 Perform clinical assessment and contribute to planning nursing care

Elements:

1. Collect and interpret health data.

2.Undertake admission and discharge procedures

3. Contribute to planning the nursing care of a person

4. Contribute to ongoing development of individual nursing care plans.


Learning Outcomes

The critical learning for this course takes place in clinical placement within the health sector and within simulations in RMIT laboratories.

You will be instructed in skills through demonstration, modelling and role-play. Skills development is supported by lectures on theory and underpinning knowledge, classroom discussions, group work, research and reflective practice.

On completion of this course you should be able to:

  1. Collect and interpret health data.

    1.1 Introduce self and explain processes before commencing nursing assessment activities.

    1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

    1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

    1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

    1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

    1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

    1.7 Clarify the emotional and physical needs of the family or carer in supporting the person.

    1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

    1.9 Communicate immediately all deterioration concerns about the person to registered nurse.

  2. Undertake admission and discharge procedures for a person.

    2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

    2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

    2.3 Identify community support services and resources to assist in planning for discharge.

    2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

  3. Contribute to planning the nursing care of a person.

    3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

    3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs.

    3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

  4. Contribute to ongoing development of individual nursing care plans

    4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

    4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

    4.3 Ensure nursing care plan is based on principles of best practice and risk assessment.

    4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.

    .


Overview of Assessment

 

Assessment Tasks


Assessment Task 1: 

Life Stages Assignment (group)

This assessment task supports knowledge assessment

 

Assessment Task 2: 

Nursing Care Plan

This assessment task supports CLOs 1, 3 & 4

 

Assessment Task 3: 

Clinical Placement

This assessment task supports CLOs 1, 2, 3 & 4


You will be provided with an assessment overview for the course and a descriptor for each assessment task.

Feedback is provided on each assessment