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

Part B: Course Detail

Teaching Period: Term1 2015

Course Code: NURS5272C

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

School: 155T Vocational Health and Sciences

Campus: City 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

Program Coordinator: Pamela Maher
Phone: +61 3 9925 4299

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


2. Undertake client assessment for admission and discharge


3. Analyse client health assessment data and observations


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


5. Prepare for client discharge


1. Collect data that contributes to client health care plan
2. Undertake client assessment for admission and discharge
3. Analyse client health assessment data and observations
4. Contribute to the development of individual care plans for clients
5. Prepare for client discharge

Performance Criteria:

1.1 Ensure appropriate introductions and explanations precede all nursing assessment & interventions
1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acruity
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 of carer (if client is unavailable)
1.10 Identify the emotional and physical needs of family and significant others in supporting the client
1.11 Document & 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
2.1 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, psychological and contextual client factors
2.4 Follow organisational policies and procedures relating to client participation
2.5 Undertake client admission with the understanding of processes involved and key issues to be addressed
2.6 Take into account individual’s values and attitude regarding their 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
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 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 psychological needs in documentation
3.7 Respect cultural, spiritual and religious wishes during nursing assessment
3.8 Use client history as part of planning care in line with health organisation requirements
4.1 Conduct a holistic 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

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

  • Student discussion & Group Work
  • Road Maps

Teaching Schedule

Lesson 1: Introduction to Unit

Lesson 2: Growth and Development

Lesson 3: Holistic Assessment

Lesson 4: Holistic Assessment

Lesson 5: Admission

Lesson 6: Discharge

Lesson 7: Mobility

Lesson 8: Documentation

Lesson 9: Laboratory and Lecture consolidation

Lesson 10: Nursing care Plans

Laboratory 1:
Station 1: Hand hygiene
Station 2: Collecting specimens
Station 3: FWT

Laboratory 2:
- Holistic System Assessment

Laboratory 3: Admission and discharge of a patient
- Demonstrate how to accurately admit and discharge a patient
- Provide students with case studies to consildate the process
- Height & weight
- Documentation

Laboratory 4:
Station 1: Observations
- Neurovascular Observation
- Neurological ObservationsStation 2: Elimination
- Bed Pans
- Bottles

Laboratory 5: Hurdle Assessment
- Perform Pain assessment
- Neurological Observation
- Holistic System Assessment
- Obtain a specimen correctly

Learning Resources

Prescribed Texts

Kozier and Erbs ‘ Fundamentals of Nursing’. (2010). 1st edition. Pearson: Australia


Other Resources

Recommended reading:
- Crisp, J Taylor, C 2009 Potter and Perry’s fundamentals of nursing 3e, Chatswood
- Flinders University, Come into my World
- Funnell, R Koutoukidis, G and Lawrence, K 2009 Tabbner’s nursing care 5e, Chatswood

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

All assessment tasks will be presented at first lesson of this course

Assessment expectations and requirements will be discussed at first lesson

All assessment tasks in this course must have a competence grade to be deemed competent in this course

Classroom attendance 80% requirement

Clinical Placement 100% requirement

Course must have a competent grade awarded to be able to move to the next phase of the program

Assessment Matrix

See assessment matrix on Blackboard

Other Information


Re-submission of assessment

One further opportunity to demonstrate Clinical Lab competence, will be provided to students if not deemed Satisfactory at the time of clinical assessment.

Re-submission of Written work, or other assessments , (once only. Excluding Exams) can be granted on recommendation from the teacher and approval by Program Coordinator.


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:


Is an online service, in to which teachers and students submit student assignments into a large database, via Blackboard, refer Turnitin website

Course Overview: Access Course Overview