The professional caregiver is able to autonomously and independently collect patient/client data based on regulations and draw conclusions regarding the professional care process. | The professional caregiver is able to: - lead a conversation on the nursing anamnesis with the patient/client and relevant others using anamnesis templates (see also CA.6.1 and CA.A.2),
- observe changes in patient’s/client’s symptoms (e.g. breathing, cardiovascular, fluids, altered consciousness, type and severity of pain, skin, urinary, digestive, behaviour, cognitive abilities),
- use scales and tools to assess the patient’s/client’s health (e.g. Behavioural Pain Score, Wong-Baker Faces Pain Rating Scale, McGill Pain Questionnaire),
- continuously update the nursing anamnesis,
- gather data from an in-depth structured interview and combine it 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 type of physician needs to be involved and initiate a visit,
- monitor the patient's/client’s health using special equipment (e.g. surveillance monitor, pulse oximeter) (see also CA.3.5)
- draw conclusions based on changes in the appearance of the patient/client (e.g. due to pharmacotherapy),
- organise and record data that has been gathered (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 their own behaviour when dealing with changes in the patient/client (e.g. breathing, cardiovascular situation),
- describe scales/indicators for patient/client 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 the pathophysiology of diseases (e.g. cognitive/mental and emotional disorders, role performance/social functioning disorders),
- describe their own behaviour in an 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 nursing care assessment (e.g. depression, mania),
- explain complex symptomatology of diseases and associated special care assessments (e.g. sepsis, heart attack, stroke, gastrointestinal bleeding),
- explain correct cognitive functioning indicators (e.g. thinking, memory, consciousness, communicative ability, speech, vision, hearing, mood, emotions),
- describe laboratory parameters and their meaning (e.g. blood coagulation, blood count, drug levels, urinary status).
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