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: leeanne.mond@rmit.edu.au
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 |
Element: |
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 |
Element: |
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 |
Element: |
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 |
Element: |
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 |
Element: |
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 |
References
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:
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.
www.rmit.edu.au/brwse:ID=ad)oagg9uc111
Plagarism:
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
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www.rmit.edu.au/students/academic-integrity
Course Overview: Access Course Overview