Course Title: Implement and evaluate a plan of nursing care

Part B: Course Detail

Teaching Period: Term2 2011

Course Code: NURS5216C

Course Title: Implement and evaluate a plan of nursing care

School: 155T Life & Physical Sciences

Campus: Bundoora Campus

Program: C5246 - Diploma of Nursing (Enrolled/Division 2 nursing)

Course Contact : Kalpana Raghunathan

Course Contact Phone: +61 3 99256649

Course Contact

Name and Contact Details of All Other Relevant Staff

Nominal Hours: 100

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.

Pre-requisites and Co-requisites

This unit should be assessed after achievement of the following related competency unit:
• HLTAP401A Confirm physical health status

The unit is recommended to be assessed in conjunction the following related competency units:
• HLTAP501A Analyse health information
• HLTOHS300A Contribute to OHS processes in the health industry
• HLTEN509A Apply legal and ethical parameters to nursing practice
• HLTEN502A Apply effective communication skills in nursing practice

This competency unit incorporates the content of:
• HLTEN405A Implement basic nursing care

Course Description

This competency unit describes the knowledge and skills required to implement nursing care plans for individual clients and evaluate the care provided in a range of health environments.

National Codes, Titles, Elements and Performance Criteria

National Element Code & Title:

HLTEN504A Implement and evaluate a plan of nursing care


1. Establish and maintain therapeutic relationships with clients

Performance Criteria:

1.1 Identify actual and potential nursing care needs in consultation/collaboration with the client
1.2 Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse
1.3 Introduce and explain all nursing interventions, using appropriate language and interpersonal skills to address the diverse needs of clients and health care settings
1.4 Establish and maintain a safe environment through effective communication with clients, family and carers
1.5 Advocate for clients within the enrolled nurse scope of practice
1.6 Work effectively with clients from a range of cultural, spiritual and religious backgrounds, taking action to address cultural factors that may impact on nursing practice
1.7 Incorporate health teaching into practice within role responsibility
1.8 Demonstrate responsibility and accountability for implementing nursing care within the Enrolled Nurse scope of practice


2. Assist client in activities of daily living

Performance Criteria:

2.1 Explain to client the importance of hygiene and grooming to achieving health outcomes
2.2 Assist clients to address hygiene, dressing and grooming needs
2.3 Describe conditions which affect the oral cavity and demonstrate effective oral hygiene to client
2.4 Identify client nutritional needs in consultation/ collaboration with client and their significant others
2.5 Assist clients with their diet and fluid intake and ensure client’s nutritional needs are met in consultation/collaboration with registered nurse
2.6 Apply strategies to assist clients with diet and fluid intake
2.7 Recognise and manage emergency situations associated with diet and fluid intake
2.8 Assist clients with key aspects of elimination
2.9 Explain and demonstrate to clients key factors associated with fluid balance and bowel charts
2.10 Assist with respiratory function especially deep breathing and coughing exercises
2.11 Use appropriate measures to promote comfort, rest and sleep


3. Assist with movement of clients

Performance Criteria:

3.1 Apply the principles and techniques of safe manual handling and principles of ‘no-lift’ policy when assisting clients with movement
3.2 Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate
3.3 Actively encourage clients to contribute to their own mobility
3.4 Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved
3.5 Identify common pressure area sites with reference to the needs of each individual client and implement appropriate strategies to prevent and manage decubitus ulcers
3.6 Identify and describe to clients factors contributing to the formation of decubitus ulcers and practices to avoid breakdown of pressure areas


4. Prepare clients for procedures

Performance Criteria:

4.1 Provide each client with a full explanation regarding preparation for specific procedures
4.2 Maintain privacy and dignity of client throughout
4.3 Complete documentation as per organisation policy and procedures
4.4 Observe validity of consent and report any concerns to the registered nurse, as appropriate


5. Provide nursing care to meet identified needs

Performance Criteria:

5.1 Participate in the implementation of a plan of nursing care in line with duty of care and OH&S policies and procedures
5.2 Monitor the application of safe workplace procedures as per OH&S policies and organisation policies and procedures
5.3 Monitor the application of infection control principles in all work activities
5.4 Prioritise work activities to meet acuity of client needs and maintain a balanced approach to own workload
5.5 Work in a manner that maintains the client’s privacy and dignity and demonstrates best practice based on a full range of relevant information including scientific rationale
5.6 Undertake nursing procedures as delegated within the nursing team and scope of practice
5.7 Apply strategies to promote comfort, rest and sleep
5.8 Implement appropriate nursing actions to prevent and manage decubitus ulcers in consultation/ collaboration with a registered nurse
5.9 Implement appropriate immediate action to address urgent needs and document and report as appropriate
5.10 Implement risk prevention strategies appropriate to delivery of nursing care
5.11 Maintain accurate documentation and adhere to reporting requirements to support safe practice as per organisation policies and procedures


6. Monitor and evaluate clients during care

Performance Criteria:

6.1 Maintain ongoing observation and assessment during nursing care
6.2 Monitor the use of diagnostic tools and document results
6.3 Monitor and evaluate client progress and changes implemented within the nursing role
6.4 Assess and document changes in client independence or pain tolerance within scope of Enrolled Nurse practice
6.5 Record and report changes in condition/baseline data/behaviour to the registered nurse, as appropriate
6.6 Document evidence of client outcomes in nursing care plan
6.7 Respond to and report situations of risk to registered nurse
6.8 Identify and respond appropriately to signs and symptoms of common emergency situations
6.9 Demonstrate respect for the client’s attitudes and values in regard to resuscitation
6.10 Use emergency codes correctly
6.11 Initiate CPR according to organisation procedures


7. Prepare the client for discharge in consultation /collaboration with registered nurse

Performance Criteria:

7.1 Clarify client needs for community support services on discharge and identify appropriate community support services to the client
7.2 Promote client awareness and understanding through health education within the enrolled nurse scope of practice
7.3 Ensure client has all requirements for discharge: next GP’s appointment: medications; and any referrals
7.4 Complete documentation as per policy and procedure


8. Evaluate nursing care provided

Performance Criteria:

8.1 Evaluate own contribution to nursing care in consultation/collaboration with the client and registered nurse
8.2 Evaluate implementation of plan of nursing care in consultation/collaboration with the multidisciplinary team and/or registered nurse
8.3 Evaluate nursing care in light of potential and actual client outcomes
8.4 Evaluate risk prevention and management strategies applied in delivery of nursing care
8.5 Demonstrate an understanding of implications and risks related to alterations in normal physiological functioning and hospitalisation, and may relate to problems of the body systems
8.6 Document and report all aspects of evaluation of nursing care provided

Learning Outcomes

On completion of this unit the participant demonstrates the knowledge and skills required to impement nursing care plans for individual clients and evaluate the care provided in a range of health environments.

Details of Learning Activities

Participation in formal lectures, small group discussions, case study, participate in nursing laboratory skill sessions
Perform elements of competence as designated for this learning segment to the required standard during clinical placement
Self directed learning activities

Teaching Schedule

Semester 1 & 2

Learning Resources

Prescribed Texts

Brown, D., Edwards, H. (eds) 2008, 2nd ed., Lewis’s medical surgical nursing; assessment and management of clinical problems, Marrickville, N.S.W. : Elsevier Australia.
Crisp, J and Taylor, C. 2009. Potter & Perry’s Fundamentals of Nursing. 3rd Ed Elsevier
Funnell, R., Koutoukidis, G., Lawrence, K. 2009, Tabner’s Nursing Care: Theory and Practice, 5th Ed., Australia : Churchill Livingstone: Elsevier
Hutton, A. R. (2006) Introduction to Medical Terminology for Health Care (4th Ed.) Chruchill Livingstone Elsevier
Webster, M. (2005) Merriam-Webster’s Medical Desk Dictionary. Revised Edn. New York: Thompson-Delamarood


Other Resources

Perry, A. & Potter, P.A. 2010, Clinical Nursing Skills & Techniques, 7th Ed., Mosby
Tollefson, J. (2010) Clinical Psychomotor Skills Assessment Tools for Nursing Students. 4rd Ed. South Melbourne. Cengage

Overview of Assessment

Assessed in conjunction with HLTEN503A  - Contribute to client assessement and develop a nursing care plan .

A comprehensive client assesemnt and nursing care plan .

Assessment Tasks

Assessed in conjunction with HLTEN503A - Contribute to client assessement and develop a nursing care plan
Assignment- case study & nursing care plan
Clinical placement competency assessment

Assessment Matrix

Case study nursing care plan weight 100%
Clinical placement competency assessment

Course Overview: Access Course Overview