Course Title: Implement and evaluate a plan of nursing care

National Element Code & Title:

HLTEN504A Implement and evaluate a plan of nursing care

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

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

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

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

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

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

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

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

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