Course Title: Implement and evaluate a plan of nursing care

National Element Code & Title:

HLTEN504C 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/Division

2 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/Division 2

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

HLTEN504C Implement and evaluate a plan of nursing care Date this document was generated: 18 September 2012

Approved

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 WHS policies

and procedures

5.2 Monitor the application of safe workplace

procedures as per WHS 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

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

HLTEN504C Implement and evaluate a plan of nursing care Date this document was generated: 18 September 2012

Approved

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/Division 2 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/Division 2

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

HLTEN504C Implement and evaluate a plan of nursing care Date this document was generated: 18 September 2012

Approved

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

HLTEN504C Implement and evaluate a plan of nursing care Date this document was generated: 18 September 2012

Approved