28993 Respond to changes and perform routine clinical tasks and/or observations in a health or wellbeing setting
Level 4 5 credits
Issue 1.0

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Introduction ............................................................................................................................. 1
Observations and clinical tasks ................................................................................................ 2
Examples of observations and clinical tasks ........................................................................ 2
Provide information to the person .......................................................................................... 4
Observe changes ...................................................................................................................... 6
Your role in observing changes ........................................................................................... 6
Respond to changes ............................................................................................................... 10
Your role in responding to changes ................................................................................... 10
Use strategies to respond to changes ................................................................................... 12
Manage risk ....................................................................................................................... 12
Provide information ........................................................................................................... 13
Record and report changes ................................................................................................... 14
Your role in recording and reporting changes ................................................................... 14
Glossary.................................................................................................................................. 16
Changes and routine tasks (US 28993) Learning Guide © Careerforce – Issue 1.0 – December 2015

Changes and routine tasks (US 28993) Learning Guide © Careerforce – Issue 1.0 – December 2015

As a support worker it is likely that you will carry out routine observations and/or clinical tasks as part of your role. These observations and/or clinical tasks will depend on your role and responsibilities and the requirements of your organisation’s policies and procedures. This learning guide will help you understand how to carry out routine observations and clinical tasks, and how to respond to any changes in a person’s health that you observe as part of that process.
This guide supports your learning and prepares you for the unit standard assessment. The activities and scenarios should be used as a general guide for learning.
This guide relates to the following unit standard:
 28993 Respond to changes and perform routine clinical tasks and/or observations in a health or wellbeing setting (level 4, 5 credits).
This guide is yours to keep. Make it your own by writing notes that help you remember things, or where you need to find more information.
Follow the tips in the notes column.
You may use highlight pens to mark important information and ideas, and think about how this information applies to your work.
You might find it helpful to talk to colleagues or your supervisor.
Finish this learning guide before you start on the assessment.
This topic will help you to:
 perform routine observations and/or clinical tasks under the direction of a health professional.
 provide information to a person about any observations or clinical tasks they are undergoing or receiving.
 observe changes in a person’s condition and/or symptoms.
 use strategies to respond to changes you observe.
 record and report the changes in a person’s condition and/or symptoms.
More info
If you have a trainer, they should give you all the forms that you need for this topic.
Changes and routine tasks (US 28993) Learning Guide © Careerforce – Issue 1.0 – December 2015
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Part of your role as a support worker will be to routinely observe people in your care and carry out certain clinical tasks. Exactly how these duties need to be carried out will depend on: your role and responsibilities within your work team. what your workplace policies and procedures say.
 how you are directed or delegated by the health professional you work with.
Some examples of routine observations and clinical tasks you may be required to perform are given below.
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Depending on your workplace and role, the following are examples of routine observations and clinical tasks that you may be required to perform:
 systolic and diastolic blood pressure monitoring. blood glucose monitoring. body temperature monitoring. oxygen status monitoring. heart rate monitoring. body weight monitoring. breathing monitoring (asthma). mood monitoring (mental issues). wound management. bowel management. administration of medication. catheter care. administration of oxygen.
 other observations and/or clinical tasks as directed.
You need to learn what the normal parameters are for the observations and clinical tasks that you perform so that you know when to make a referral or to report. You are not allowed to interpret any results or make any clinical judgements.
You may often work as part of a multidisciplinary team of people with different roles, professions and expertise. In these situations, your role and responsibilities may be different, so it’s important that you know what they are.
Changes and routine tasks (US 28993) Learning Guide © Careerforce – Issue 1.0 – December 2015
More info
The learning guide for US 28984
Working
collaboratively
(level 4) looks at multidisciplinary teams in further detail.
2

Question
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Go to your workplace policies and procedures and the description of your role. Research what they say about:
 the observations and/or clinical tasks you may perform in your workplace. the observations and/or clinical tasks you may not perform in your workplace. who will be directing and delegating tasks to you.
Do it
Research what routine observations and/or clinical tasks you may and may not perform in your workplace. Talk to your supervisor if you are unsure.
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When you are performing routine observations and clinical tasks, you must know how to pass on that information to the person you are supporting and what information to provide.
What information do you give to the person you are observing or supporting? It is essential to provide accurate and appropriate information to the person (and their family/whānau) about their care and treatment.
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In giving them this information, you need to consider:
 your role and level of responsibility.
 how you are directed or delegated by a health professional. what your workplace policies and procedures say. what the Code of Rights says.
 the information that needs to be communicated.
 how to communicate it in a way that the person will understand.
More info
The learning guide for
US 28987 Personal
plans (level 4) contains some excellent information about providing information to the person you are supporting. You will find it useful to review this information.
Communicate
It Is important to know what a person is entitled to under the Code of Rights.
Key words
Code of Rights a set of rights for the people who use a healthcare service
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Write
Choose two different routine observations and/or clinical tasks that you do in your workplace. Write down what you might say to the person you are supporting as to why you are completing each observation or clinical task.
Observation and/or clinical task
What you might say
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Another important part of your role is to be able to recognise changes in the condition and/or symptoms of a person.
Part of your duties in performing routine observations and clinical tasks, as a support worker, is to recognise and note when there are changes.
You are required to observe changes under the direction and delegation of a health professional in your organisation. Your workplace will also have its own policies and procedures to guide you on exactly what is required.
Please note that, although the information in this part provides a useful summary on this topic, you may also want to find and review the learning guide for unit standard 27459 Observe and respond to changes
(level 3) for more detailed information.
Observing a person for changes in their condition and/or symptoms involves knowing the person and knowing the changes you might expect in their condition and/or symptoms. You need to be able to recognise the different types of change when they happen.
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To be able to describe and report a change in someone’s health or functional status, you need to establish how the person was before the change happened. In doing this, consider the following questions.
What is considered ‘normal’ for the person?
What have you noticed while caring for them previously?
 What does their personal plan (or other appropriate health care records) say?
 What types of change do you need to be looking out for specifically?
What have you noticed that might not be ‘normal’ for them?
What is the person or their family/whānau telling you?
 What is the health professional you are assisting telling you?
More info
You may want to refer to the learning guide for US 27459 Observe and respond to
changes for more detailed information.
Do it
Find and review this level 3 information on observing and responding to changes.
Key words condition personal plan a state relating to a person's health and functional status (ability to perform activities of daily life), usually related to a specific illness, disease or disability a written document that outlines how your organisation will support a person's needs
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People’s health is affected by the status of their condition and/or symptoms. Consider which of the following applies to the person’s condition and/or symptoms and, therefore, what you might expect to see. Is the condition and/or symptoms: permanent – this means it will always be with them. stable – this means it does not change much over time.
 unstable – this means it can and probably will change.
 part of a healing process – this means it is experienced as part of returning to health.
 part of the aging process – this means it is experienced as part of growing older.
 part of a disease process – this means it is experienced as part of the status of a disease.
 life-limiting – this means it cannot be cured and will likely lead to the person’s premature death; it will also often require special or palliative care.
 a change from wellness – this means any decline in a person who was previously well.
In making your routine observations you may notice that a person’s general state of health has deteriorated. For example, a wound may not be healing as well as is expected, or they may be bruising more readily.
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You’ll be looking out for any changes in any areas of the person’s life, including:
 physical – any internal or external changes to their body, such as weight loss or gain.
 environmental – changes in their surroundings or lifestyle choices within their surroundings, such as tidiness or cleanliness.
 emotional – changes in how they feel about themselves, others or the world around them, such as positive or negative moods or changes in their level of confidence.
 cognitive – changes in their perception, intuition or reasoning, such as mental ability, memory or ability to perform tasks.
 psychosocial – changes in how they behave, such as sleeping, eating or interacting with others.
 spiritual – changes in their spirituality; they may turn to their religion as they go through hard times or when nearing death.
Changes can include improvements as well as deteriorations.
If changes are occurring in more than one area, this could be a sign that there is a serious issue.
You need to be aware of anything that your workplace policies and procedures say about observing a person for changes in condition and/or symptoms.
Key words cognitive psychosocial how a person acquires knowledge, including matters of perception, intuition and reasoning how the person relates to and interacts with other people the worsening or decline of a person's health deterioration
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Write
Choose two different routine observations and/or clinical tasks that you do in your workplace. Write down the circumstances in which you would report a change for each observation and/or clinical task.
Observation and/or clinical task
When would you report a change?
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Now you know how to recognise changes in a person’s condition and/or symptoms, we will look more closely at how to respond appropriately to any changes that you observe. This is about making good decisions based on the information you have collected.
As a support worker, your role is to observe a change (or changes) and recognise when the changes you’ve observed could affect the person’s health or functional status, or the delivery of their personal plan.
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In responding to what you observe, you need to:
 consider the significance of any changes.
 evaluate the impact of these changes.
 decide on strategies to use to respond to the changes.
 always act in the best interests of the person. uphold the person’s rights to privacy, dignity and autonomy. respond in line with the person’s personal plan and your workplace policies and procedures.
If you are not sure, describe the situation to your delegating health professional and ask for their guidance.
You need to always respond to changes in line with your workplace policies and procedures.
Key words autonomy dignity privacy strategies a person's right to make decisions for themselves a person's right to be treated respectfully, taking into account the needs, values and beliefs of different cultural, religious, social and ethnic groups, including the needs, values and beliefs of Māori a person's right to prevent their confidential information being shared with others without their consent plans, methods or a series of actions for achieving a desired outcome, goal or result
More info
The learning guide for
US 27459 Observe and respond to changes
(level 3) also contains more information that you need to know about responding to changes. Find and review this now.
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Question
Go to your workplace policies and procedures and the description of your role. Research what they say about your role in responding to changes in a person’s condition and/or symptoms.
Remember that if you work as part of a multidisciplinary team of people, your role and responsibilities may differ, so it’s important you know what they are.
Do it
Research what your role is in responding to changes in a person’s condition in your workplace. Talk to your supervisor if you are unsure.
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You are probably the one who will have the most contact with the person you are supporting. You may identify early warning signs and these should be documented in the individual risk management plan, and reported, recorded and acted upon.
A support worker may also contribute to managing risk through being involved in a multidisciplinary team. For example, attending meetings, and providing feedback or reports on individual people.
Keeping people safe from harm must always be a priority. You will need to know their risk management plan well and how to implement the plan. A risk management plan sets out how any identified risks can and should be managed.
A risk assessment is an examination of a person’s home or environment, any items within it and anyone or anything (including the person’s own behaviour) that could cause harm or lead to the abuse of individuals.
Using a risk management strategy whenever you are responding to changes in a person’s condition and/or symptoms means that you have a responsibility for:
 using your common sense and being practical in the support you offer.
• ensuring the support you give is practical and fair.
• reacting early enough to prevent a risky situation rather than waiting for it to occur.
• ensuring that you provide opportunities for the person to explore and experience their environment safely.
For example, you may identify that a person’s deteriorating condition may make showering a risk, as they could slip and fall on the wet area.
You identify this as a moderate risk, so you will need to stay with the person to reduce the level of risk. You could use a non-slip mat, a shower chair, or shower rails, to reduce the risk of an accident.
You will need to record this and communicate this change to the person, their family and whānau and your supervisor/manager.
The effectiveness of this risk management strategy will be monitored through health and safety checks and reviewed if necessary.
More info
You can read more about working collaboratively in a multidisciplinary team in the learning guide for US 28984 Working
collaboratively.
More info
You can read more about risk management strategies in US 23393
Apply a risk
management plan.
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Your responsibility is to inform the relevant health professionals of any changes in a person’s condition and/or symptoms. You need to provide these health professionals with quality information so that decisions can be made to best support the person’s needs.
This forms part of the duty of recording and reporting changes that we will look at in the next part of this learning guide.
It is essential to provide appropriate information to the person (and their family/whānau) about their care and treatment. You may wish to refer back to the first part of this learning guide where we discussed this.
Do it
Find and familiarise yourself with your organisation’s risk management procedures relating to support workers’ responsibilities in responding to changes in a person’s condition.
Question
How would you provide information to the person or family/whānau in your workplace about:
 a minor change in a person’s condition and/or symptoms?
 a major change in a person’s condition and/or symptoms?
Think about
Think about how you would provide information to the person in each of these situations.
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You may not be able to know why a change (or changes) is occurring, but it is your responsibility to record and report change appropriately, accurately and promptly. Review the following questions with your supervisor and ensure that your practice of recording and reporting is correct.
Ensure you understand why it is important to record and report changes. If you are unsure, ask your manager or supervisor.
What facts about any changes do you need to record?
Where do you record these changes?
How do you record them?
When do you record them?
Who do you need to tell about any changes?
When do you report the changes to them?
How do you report the changes to them?
Understanding how these procedures operate in your workplace is very important so that decisions can be made that will best meet the person’s needs. It is also important to tell the person you are supporting, their next of kin and your supervisor that you have reported changes (especially if it seems serious) to a health professional.
Do it
Review this information with your manager or supervisor.
Think about
How will you record and report changes in the condition and/or symptoms of a person under your care in your workplace?
Communicate
It Is important to communicate with the person and their family/whānau.
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There are various documentation tools and mechanisms available to help you promote effective communication and to record and report changes. Examples of this may include SOAP (recommended by the New
Zealand Nurses Organisation) or SBARR.
Question
What is SBARR?
What does SBARR stand for?
How can you use this tool in your role?
What do your workplace policies and procedures say about recording and reporting changes in the condition and/or symptoms of a person?
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Key words autonomy
Code of Rights cognitive condition deterioration dignity personal plan privacy psychosocial strategies a person's right to make decisions for themselves a set of rights for the people who use a healthcare service how a person acquires knowledge, including matters of perception, intuition and reasoning a state relating to a person's health and functional status (ability to perform activities of daily life), usually related to a specific illness, disease or disability the worsening or decline of a person's health a person's right to be treated respectfully, taking into account the needs, values and beliefs of different cultural, religious, social and ethnic groups, including the needs, values and beliefs of Māori a written document that outlines how your organisation will support a person or group's needs a person's right to prevent their confidential information being shared with others without their consent how the person relates to and interacts with other people plans, methods or a series of actions for achieving a desired outcome, goal or result
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