Course Title: Undertake basic client assessment

National Element Code & Title:

HLTEN403A Undertake basic client assessment

Performance Criteria:

HLTEN403A/01 Collect data relating to client health
1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions
1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
1.3 Perform other clinical measurements/ assessments such as activities of daily living
1.5 Document current client health practices, issues and needs
1.6 Document and report variations from normal on a regular basis
1.7 Involve client in the process of data collection wherever possible
1.8 Undertake ongoing data collection, such as vital signs

HLTEN403A/02 Undertake client assessment for admission and discharge
2.1 Collect client-based data for admission and / or discharge planning
2.2 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
2.3 Follow organisation policies and procedures relating to client participation
2.4 Undertake client admission with understanding of processes involved and key issues to be addressed
2.5 Take into account individual’s values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate
2.6 Document client information, such as community resources, to assist in planning for discharge
2.7 Accurately record and report admission and discharge information
2.8 Respect cultural, spiritual and religious wishes during nursing assessment

HLTEN403A/03Contribute to planning nursing care for clients in a health care environment
3.1 Contribute to development of nursing care plans within the context of the area of health care and implement in consultation/collaboration with the registered nurse
3.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice
3.3 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
3.4 Identify and implement stress management techniques for clients

HLTEN403A/04 Prepare for client discharge
4.1 Clarify client needs for community support services on discharge and identify appropriate community support services to the client
4.2 Promote client awareness and understanding through health education within the enrolled nurse scope of practice
4.3 Ensure client has all requirements for discharge:
- next GP’s appointment
- medications
- any referrals
4.4 Ensure documentation is completed as per policy and procedure

HLTEN403A/05 Work with clients across the life span
5.1 Work with an understanding of the different approaches to the concepts of growth and development
5.2 Work with an awareness of differing influences on human development, of genetics and environment
5.3 When working with clients across the life span, take into account differences in physical growth, cognitive and motor development, psychosocial development and issues associated with different stages of development

Marieb, E. 2006 Essentials of anatomy and physiology 2nd Ed. Benjamin Cummings: San Fransisco
Crisp, J and Taylor, C. 2009 Potter & Perry’s Fundamentals of Nursing 3rd Ed. Elsevier: Sydney 

Chabner, DE 2003 Medical Terminology: a short course Saunders:Philadelphia
Harris, P, Nagy, S and Vardaxis, N 2006 Mosby’s Dictionary of Medicine, Nursing and Health Professions Elsevier:Sydney