Course Title: Contribute to client assessment and developing nursing care plans

Part B: Course Detail

Teaching Period: Term1 2017

Course Code: NURS5273C

Course Title: Contribute to client assessment and developing nursing care plans

School: 155T Vocational Health and Sciences

Campus: Bundoora Campus

Program: C5313 - Diploma of Nursing (Enrolled-Division 2 Nursing)

Course Contact: Leeanne Mond

Course Contact Phone: +61 3 9925 4837

Course Contact Email:

Name and Contact Details of All Other Relevant Staff


Bianca Rohlje

+61 3 99254809

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.

Pre-requisites and Co-requisites


This unit of competency is co delivered with HLTAP501C Analyse Health Information. This co delivered unit has the prerequisite attached HLTAP401B Confirmed Physical Health Status which must be successfully completed prior to the commencement of this unit.

Course Description

This unit of competency describes the skills and knowledge required of an Enrolled/Division 2 Nurse in contributing to the development of individualised health care plans by collection of data captured during a client’s preliminary and ongoing health assessments. Assessment is based on a lifespan approach

The knowledge and skills described in thiscompetency unit are to be applied withinjurisdictional nursing and midwifery regulatory authority legislative requirements. Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurse and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements

National Codes, Titles, Elements and Performance Criteria

National Element Code & Title:

HLTEN503B Contribute to client assessment and developing nursing care plans


1. Collect data that contributes to client health care plan

Performance Criteria:

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

1.4 Record lifestyle patterns and coping mechanisms in documentation

1.5 Document current client health practices, issues and needs

1.6 Document gender, age, cultural, religious and/or spiritual data in preliminary health assessment

1.7 Identify the likely impact of specific health care on the client's health

1.8 Involve client in the process of data collection wherever possible

1.9 Access client information from appropriate family member or carer (if client is unable)

1.10 Identify the emotional and physical needs of family and significant others in supporting the client

1.11 Document and report variations from normal on a regular basis

1.12 Validate extraordinary findings immediately, document and report abnormalities to the registered nurse

1.13 Undertake ongoing client assessment


2. Undertake client assessment for admission and discharge

Performance Criteria:

2.1 Collect client-based data for admission and /or discharge planning

2.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice

2.3 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors

2.4 Follow organisation policies and procedures relating to client participation

2.5 Undertake client admission with understanding of processes involved and key issues to be addressed

2.6 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

2.7 Document client information, such as community resources, to assist in planning for discharge

2.8 Accurately record and report admission and discharge information


3. Analyse client health assessment data and observations

Performance Criteria:

3.1 Accurately interpret information gained from health assessments and observations as being within normal range and/or refer to appropriate health care colleague for interpretation

3.2 Report change in client health status in a timely manner to the appropriate health care colleague

3.3 Identify the likely cause of any significant variation(s) from normal in relation to providing care

3.4 Reflect consideration for age and developmental state of client in performance of clinical nursing assessment

3.5 Analyse physiological aspects of human growth and its impact on client health

3.6 Reflect the client's interests, physical, emotional and psychosocial needs in documentation

3.7 Respect cultural, spiritual and religious wishes during nursing assessment

3.8 Use client health history as part of planning care in line with health organisation requirements


4. Contribute to the development of individual care plans for clients

Performance Criteria:

4.1 Conduct a holistic health assessment reflecting the nursing philosophy or theory of the organisation in consultation/collaboration with a registered nurse

4.2 Use appropriate health assessment tools and appropriate terminology in documentation as well as a variety of sources and clinical situations

4.3 Use a problem solving approach in the development of care plans for clients

4.4 Discuss care requirements with the client and/or their family or significant other to ensure information is accurate

4.5 Verify client based information to ensure client's uniqueness and individuality is reflected in the care plan

4.6 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse

4.7 Record age and gender issues in the development of individualised care plans

4.8 Incorporate cultural, spiritual and religious beliefs in the development of individualised care plans

4.9 Ensure documentation reflect the client's needs: physical, emotional, spiritual and psychosocial

4.10 Ensure nursing care plan addresses principles of best practice and risk assessment and identifies stress management techniques for clients


5. Prepare for client discharge

Performance Criteria:

5.1 Identify appropriate community support services to the client

5.2 Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice

5.3 Ensure client has all requirements for discharge: next GP's appointment; medications; and any referrals

5.4 Ensure documentation is completed as per policy and procedure

Learning Outcomes

At the end of this unit students should be able to:

• Collect data that contributes to client health care plan
• Undertake client assessment for admission and discharge
• Analyse client health assessment data and observations
• Contribute to the development of individual care plans for clients
• Prepare for client discharge

Details of Learning Activities

            Classroom lectures, use of on-line resources, group discussion and practical demonstrations

Teaching Schedule


Lesson 1: Growth and development

Lesson 2: Documentation, admission and discharge

Lesson 3: Developing a plan of nursing care

LAB 1: Health assessment

Lesson 4: Assessment skills

Lesson 5: Vital signs

Lesson 6: Pain, neurological and neurovascular assessments

LAB 2: Vital signs

Lesson 7: Specimen collection

Lesson 8: Understanding the impact of emergency conditions

LAB 3: Vital signs

Lesson 9: Implementing services

Lesson 10: Poster presentations

LAB 4: Neurological and neurovascular observations

LABs 5 & 6 Skills assessment

Learning Resources

Prescribed Texts

                    Berman, A., Snyder, S., Kozier, B. & Erb, G., (2012). Kozier & Erb’s Fundamentals of Nursing: Volumes 1 & 2, (9th ed.). Pearson, Australia


                    Funnell, R., Koutoukidis, G. & Lawrence, K. (2009) Theory and Practice: Tabbner’s Nursing Care 5E. Elsevier, NSW

Other Resources

            Tollefson ‘Clinical Psychomotor skills: assessment tools for nursing students’ textbook

Overview of Assessment

Underpinning knowledge for this unit of comtency will be assessed via the following methods:

  • Written Examination / Written Assessment
  • Practical Assessment
  • Clinical Placement

Assessment Tasks


1. Online quiz x1

2. Poster presentation

3. Case study

4. Clinical skills lab assessment: vital signs (temperature, pulse rate, blood pressure and respiratory rate), oxygen saturation and blood glucose monitor.

Refer to assessment schedule for submission dates.

Each assessment will be marked as either Satisfactory or Not Satisfactory.

In order to achieve overall Competency for this course, all assessments must achieve a Satisfactory result.

Assessment Matrix

             Refer to Assessment Matrix available on Blackboard

Other Information


Each assessment will be marked a either Satisfactory or Not Satisfactory.

In order to achieve overall Competency for this course, all assessments must achieve a Satisfactory result.

You are expected to attend all classes and LAB sessions.


Reassessment of students who have attempted to undertake a practical assessment and have attended all LAB sessions will be given a further opportunity to demonstrate a Satisfactory result.

Reassessment/resubmission of all other assessments listed, may be granted on the recommendation of the Program Coordinator in consultation/collaboration with the Teacher.

Please refer to the RMIT policies regarding special consideration, extensions of time, equitable assessment arrangements and future assessment adjustments.


Plagiarism is a form of cheating in assessment and may occur in oral, written or visual presentations. It is the presentation of the work, idea or creation of another person, without appropriate referencing, as though it is your own.


Turnitin is an online service, into which teachers and students submit student assignments into a large database. The text of a student assignment, or whatever else has been uploaded, is retained in the database. The database compares the text in the assignment against other database content which includes all of the World Wide Web, online e-journals, and previously uploaded assignments. Teachers and their students are then able to review the citation and paraphrasing used throughout the student assignment to see if any improvements are needed.

Course Overview: Access Course Overview