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Learning outcomes descriptions 1.1.b

Competence description VQTS:
1.1.b   To be able to conduct professional care assessment.    
Competence (EQF)SkillsKnowledge






The professional caregiver is autonomously and self-responsibly able to collect patient’s/client’s data based on regulations and to draw conclusions regarding the professional care process.












































The professional caregiver is able to:

  • lead a conversation to the nursing anamnesis with the patient/client and relevant others using anamneses templates (see also CA.6.1 and CA.A.2),
  • observe changes in patient’s/client’s symptoms (e.g. regarding breathing, cardiovascular, fluids, altered consciousness, type and severity of pain, skin, urinary, digestive, behaviour, cognition abilities),
  • use scales and tools for the patient’s/client’s health assessment (e.g. Behavioural Pain Score, Wong-Baker Faces pain rating scale, McGill Pain Questionnaire),
  • update the nursing anamnesis continuously,
  • to gather data from an in-depth structured interview and combine them into the nursing care assessment,
  • take over initial physical examinations to gather data (e.g. regarding the patient’s/client’s pulmonary situation, fluid balance, sensory function, simple neurological reflexes),
  • complete scales based on physical examinations,
  • decide what profession of physician need to be involved and to initiate a visit,
  • monitor the patient's health condition using special equipment (e.g. surveillance monitor, pulse oximeter) (see also CA.3.5)
  • building conclusions based on changes in the appearance of the patient/client (e.g. due to pharmacotherapy),
  • organise gathered data and to perform the documentation (see also CA.A.2).

The professional caregiver is able to:

  • explain legal regulations and consequences regarding data gathering (see also CA.B.3),
  • repeat an anamnesis interview,
  • explain one’s own behaviour when dealing with changes in the patient/client (e.g. in breathing, cardiovascular situation of the patient/client),
  • describe scales/indicators for patient’s/client's assessment (e.g. Activities of Daily Life, Instrumental Activities of Daily Living scale, Norton scale, Waterlow scale, Mini Nutrition Assessment, Glasgow Coma Scale, Body Mass Index),
  • explain pathophysiology of diseases (e.g. cognitive/mental and emotional disorders, role performance/social functioning disorders),
  • describe one’s own behaviour in initial physical examination,
  • explain the anatomy of the human heart and lungs,
  • name and explain physical diseases,
  • explain the anatomy of the human gastrointestinal tract,
  • name and explain diseases of the human skin,
  • name and explain mental diseases that reduce the patient’s/client’s compliance within the nurse care assessment (e.g. depression, mania),
  • explain complex symptomatology of diseases and associated special care assessments (e.g. sepsis, heart stroke, stroke, gastrointestinal bleeding),
  • explain correct cognitive functioning indicators (e.g. thinking, memory consciousness, communication ability, speech, vision, hearing, mood, emotions),
  • describe laboratory parameters and their meaning (e.g. blood coagulation, blood picture, drug levels, urinary status).

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