Unit of competency Outline
Information current as of
21/10/2026 10:54 AM AWST
21/10/2026 10:54 AM AWST
Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.
Deliver nursing care to acute care clients
Deliver nursing care to acute care clients
Unit of competency
National Code
HLTEN415B
HLTEN415B
State Code
D8206
D8206
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
03/08/2011
Original Release Date
25/03/2011
Nominal Hours
45
Field of Education
060309 - Critical Care Nursing
Description
DescriptorThis unit of competency describes the skills and knowledge required of Enrolled/Division 2 nurses in contributing to the care of a person with an acute health problem
General notes
N/A
Elements and Performance Criteria
1. Identify the impact of acute health problems on the client and their family.
- 1.1 Identify the clinical manifestations of presenting acute health problem(s)
- 1.2 Identify actual and potential health issues of a client presenting with an acute health problem through discussion of information gained from a preliminary health assessment with the appropriate members of the health care team
- 1.3 Use a problem solving approach to assess the impact of the acute health problem on the client and their family and the achievement of activities of daily living
- 1.4 Discuss available resources and support services with client/s and significant others where appropriate with the consent of the client
- 1.5 Maintain confidentiality in line with facility policy and procedures
2. Contribute to planning care for the client with acute health problems
- 2.1 Gather and record admission data for the client with an acute health problem, for inclusion in a care plan according to organisation policy
- 2.2 Gather and record ongoing clinical data for inclusion in the client's care plan in line with organisation policy
- 2.3 Accurately gather, document and report changes in client condition to appropriate health care team members
- 2.4 Document information gathered from client and family to assist in development of the care plan
- 2.5 Contribute information and data on the activities of daily living for the client with an acute illness for inclusion in a discharge plan
- 2.6 Contribute effectively to discussions on the care of the client with registered nurse and other members of the health team
- 2.7 Implement client discharge procedure in line with organisation policy and procedures
- 2.8 Advocate for clients in health and/or community settings
3. Perform nursing interventions to support health care of clients with acute health problems
- 3.1 Undertake nursing interventions based on predetermined plans of care
- 3.2 Ensure nursing interventions reflect client needs and individuality
- 3.3 Perform nursing interventions with respect for the dignity of the client
- 3.4 Reflect consideration of cultural and religious issues in the performance of nursing interventions
- 3.5 Encourage the client and/or their significant others to assist in the performance of nursing interventions if able
- 3.6 Consider physical, psychological and social needs in the performance of nursing interventions
- 3.7 Carry out nursing interventions in accordance with professional, legal, ethical and organisation requirements
- 3.8 Assist clients to meet their activities of daily living
- 3.9 Address gender and age issues in the performance of nursing interventions
- 3.10 Identify emergency situations and respond according to organisation policy and procedure and within legal and professional requirements
- 3.11 Contribute to and support health teaching plans for the client with an acute health problem
- 3.12 Identify appropriate psychological support and care for individual clients
- 3.13 Report and document emergency situations according to policy and procedure
- 3.14 Identify and prioritise own nursing interventions according to client needs
- 3.15 Reflect pre- and post-procedure care in nursing interventions
4. Contribute to an emergency response
- 4.1 Confirm the roles and responsibilities of members of the emergency response team
- 4.2 Participate in performing emergency resuscitation techniques
5. Contribute to pre-operative nursing care of a client
- 5.1 Contribute to collection of pre-operative client health assessment data, addressing all relevant factors
- 5.2 Assist in preparation for specific surgical procedures
- 5.3 Contribute to the nursing care of a pre-operative client
- 5.4 Ensure pre-operative care takes into account the relationship between pre-operative care and post-operative complications
- 5.5 Identify and report delivery of anaesthesia; observe validity of consent and report any concerns to the registered nurse or appropriate supervisor
6. Contribute to post-operative nursing care of a client
- 6.1 Contribute to post-anaesthetic observation of a client following surgery and report any abnormal findings to Registered Nurse
- 6.2 Accurately gather, document and report changes in client condition to appropriate health care team member
- 6.3 Provide nursing care for post-operative clients
- 6.4 Contribute to observations of the client undergoing blood transfusion
- 6.5 Work with an awareness of available drugs commonly used post-operatively for the relief of pain and nausea
- 6.6 Apply appropriate nursing actions to promote client comfort, reporting any moderate to severe pain experienced by the client to Registered Nurse
- 6.7 Respond appropriately to clients recovering from a range of anaesthesia used for general, local and epidural/spinal procedures
- 6.8 Ensure client is attending to post operative exercises
RANGE STATEMENT
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Health care settings may include:
Hospitals
Residential aged care facilities
Respite centres
Short/long stay centres
Community setting
Rural and remote settings
Plans of care could include:
Nursing care plans
Clinical pathways
Treatment plans
Medical notes
Client notes
Manual and electronic storage systems
Resident classification records
Acute health problems may include the following:
Acute renal disorders
Acute abdomen
Acute neurological disorder
Acute pain
Acute respiratory disorders
Acute unconscious state
Angina
Burns
Cellulitis
Deep Vein thrombosis
Dehydration
Elective/emergency surgery (post operative phase)
Fractures
Haemorrhage
Head injury
Myocardial infarction
Renal calculi
Sepsis
Shock
Tropical diseases
Wounds
Acute clinical nursing interventions could include:
Assist achievement of activities of daily living
Acute admission procedure
Acute wound management
Airway management
Application of anti embolism stockings
Observation and reporting of acute pain
Assessment/observation of level of consciousness
Assessment/observation of respiratory function
Complications of acute bed rest
Discharge of client
First aid
Fluid balance recording
Incentive spirometry and peak flow measurements
Neurovascular observations
Pre operative observations, exercises and care
Post operative observations, exercises and care
Preparation for medical procedure
Preparation for surgical procedure
Pulse oximetry
Tracheostomy care (established stoma)
Transfer of client - intra-facility
Transfer/evacuation of client to another facility
Common terminology associated with surgery may include:
Elective/emergency
General/local/epidural/spinal anaesthetic
Caudal/peripheral nerve block
Debridement
Skin graft
Amputation
Open reduction
Hip replacement
Craniotomy
Tonsillectomy
Appendicectomy
Laparotomy
Hysterectomy
Prostatectomy
Cataract extraction
Haemorrhage
Deep vein thrombosis
When communicating/caring for a client, the following may need to be considered:
Any physical or mental problems which may hinder communication (such as deafness or dementia, or disease processes)
Individual consideration of the following socio-economic, physiological variables will be addressed (social, gender, emotional, intellectual, language, culture)
All verbal and non-verbal interactions with client and colleagues in a range of appropriate interpersonal context
Effective communication skills include non judgemental attitude, active listening and use of culturally appropriate communication methods (verbal and non-verbal)
Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines
Observations may include, but are not limited to:
Respiratory status assessment (ie. Rate, rhythm, depth and sound)
Cardiovascular status assessment ( ie. Pulse, blood pressure)
Temperature status assessment
Oxygen saturation (ie. Triflow, peak flow, oxygen therapy)
Urinalysis
Faecal assessment
Blood sugar level
Client history may include:
Pre-existing medical conditions
Allergies
Current history
Diagnostic procedures/investigations
Allied health team recommendations
Current medication
Continence status
Skin integrity
Mobility
Nutritional status
Hydration status
Psychosocial needs
Next of kin
Previous surgery
Pre-operative assessment data may include:
Vital signs
Allergies
Age, height, weight
Urinalysis
Hydration/nutritional status
Medical/surgical history (including family history)
Prescribe and non-prescribed medications
Patterns of drug use/smoking/alcohol
Specific preparation may include:
Fasting
Skin preparation
Appropriate dress for surgical procedure
Removal of jewellery and safe storage
Administration of prescribed pre-medications
Denture removal (if necessary)
ID band/allergy ID
Check documentation is complete, including signed consent
Removal of sensory aids eg. hearing aid, glasses if required
Drugs commonly used pre-operatively may include:
Sedatives/hypnotics
Anticholinergics
Topical analgesia
Anti-angina medication
Bronchodilators
Post operative pain management strategies may include:
Patient controlled analgesia (PCA)
Narcotic infusion
Epidural analgesia
Topical analgesia
Oral analgesics
Subcutaneous/intramuscular injection analgesia
Post anaesthetic and post-operative observations may include:
Level of consciousness
Vital signs
Intravenous therapy
Indwelling catheters
Neurovascular observations
Skin colour
Fluid output - urinary, wound drainage, suction, vomitus
Indwelling catheter position
Urine output
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Health care settings may include:
Hospitals
Residential aged care facilities
Respite centres
Short/long stay centres
Community setting
Rural and remote settings
Plans of care could include:
Nursing care plans
Clinical pathways
Treatment plans
Medical notes
Client notes
Manual and electronic storage systems
Resident classification records
Acute health problems may include the following:
Acute renal disorders
Acute abdomen
Acute neurological disorder
Acute pain
Acute respiratory disorders
Acute unconscious state
Angina
Burns
Cellulitis
Deep Vein thrombosis
Dehydration
Elective/emergency surgery (post operative phase)
Fractures
Haemorrhage
Head injury
Myocardial infarction
Renal calculi
Sepsis
Shock
Tropical diseases
Wounds
Acute clinical nursing interventions could include:
Assist achievement of activities of daily living
Acute admission procedure
Acute wound management
Airway management
Application of anti embolism stockings
Observation and reporting of acute pain
Assessment/observation of level of consciousness
Assessment/observation of respiratory function
Complications of acute bed rest
Discharge of client
First aid
Fluid balance recording
Incentive spirometry and peak flow measurements
Neurovascular observations
Pre operative observations, exercises and care
Post operative observations, exercises and care
Preparation for medical procedure
Preparation for surgical procedure
Pulse oximetry
Tracheostomy care (established stoma)
Transfer of client - intra-facility
Transfer/evacuation of client to another facility
Common terminology associated with surgery may include:
Elective/emergency
General/local/epidural/spinal anaesthetic
Caudal/peripheral nerve block
Debridement
Skin graft
Amputation
Open reduction
Hip replacement
Craniotomy
Tonsillectomy
Appendicectomy
Laparotomy
Hysterectomy
Prostatectomy
Cataract extraction
Haemorrhage
Deep vein thrombosis
When communicating/caring for a client, the following may need to be considered:
Any physical or mental problems which may hinder communication (such as deafness or dementia, or disease processes)
Individual consideration of the following socio-economic, physiological variables will be addressed (social, gender, emotional, intellectual, language, culture)
All verbal and non-verbal interactions with client and colleagues in a range of appropriate interpersonal context
Effective communication skills include non judgemental attitude, active listening and use of culturally appropriate communication methods (verbal and non-verbal)
Potential resources required such as equipment, appropriate documentation, occupational health and safety guidelines
Observations may include, but are not limited to:
Respiratory status assessment (ie. Rate, rhythm, depth and sound)
Cardiovascular status assessment ( ie. Pulse, blood pressure)
Temperature status assessment
Oxygen saturation (ie. Triflow, peak flow, oxygen therapy)
Urinalysis
Faecal assessment
Blood sugar level
Client history may include:
Pre-existing medical conditions
Allergies
Current history
Diagnostic procedures/investigations
Allied health team recommendations
Current medication
Continence status
Skin integrity
Mobility
Nutritional status
Hydration status
Psychosocial needs
Next of kin
Previous surgery
Pre-operative assessment data may include:
Vital signs
Allergies
Age, height, weight
Urinalysis
Hydration/nutritional status
Medical/surgical history (including family history)
Prescribe and non-prescribed medications
Patterns of drug use/smoking/alcohol
Specific preparation may include:
Fasting
Skin preparation
Appropriate dress for surgical procedure
Removal of jewellery and safe storage
Administration of prescribed pre-medications
Denture removal (if necessary)
ID band/allergy ID
Check documentation is complete, including signed consent
Removal of sensory aids eg. hearing aid, glasses if required
Drugs commonly used pre-operatively may include:
Sedatives/hypnotics
Anticholinergics
Topical analgesia
Anti-angina medication
Bronchodilators
Post operative pain management strategies may include:
Patient controlled analgesia (PCA)
Narcotic infusion
Epidural analgesia
Topical analgesia
Oral analgesics
Subcutaneous/intramuscular injection analgesia
Post anaesthetic and post-operative observations may include:
Level of consciousness
Vital signs
Intravenous therapy
Indwelling catheters
Neurovascular observations
Skin colour
Fluid output - urinary, wound drainage, suction, vomitus
Indwelling catheter position
Urine output
EVIDENCE GUIDE
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Observation of performance in a work context is essential for assessment of this unit
Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse
Context of and specific resources for assessment:
This unit is most appropriately assessed in a simulated clinical work environment and under the normal range of clinical environment conditions, prior to assessment in the workplace
Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible
Method of assessment
Observation in the workplace
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning - verbal or written
Role play
Simulation/virtual clinical setting (laboratory) to accommodate learning
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Related units:
This unit is recommended to be assessed in conjunction with the following related competency unit:
HLTAP401B Confirm physical health status
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Observation of performance in a work context is essential for assessment of this unit
Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse
Context of and specific resources for assessment:
This unit is most appropriately assessed in a simulated clinical work environment and under the normal range of clinical environment conditions, prior to assessment in the workplace
Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible
Method of assessment
Observation in the workplace
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning - verbal or written
Role play
Simulation/virtual clinical setting (laboratory) to accommodate learning
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Related units:
This unit is recommended to be assessed in conjunction with the following related competency unit:
HLTAP401B Confirm physical health status
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9212 | HLTEN415A | Deliver nursing care to acute care clients | Unit of competency |
