Unit of competency Outline
Information current as of
21/10/2026 12:11 AM AWST
21/10/2026 12:11 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.
Undertake basic client assessment
Undertake basic client assessment
Unit of competency
National Code
HLTEN403B
HLTEN403B
State Code
D8199
D8199
TGA Status
Replaced
Replaced
DTWD Status
Deleted
Deleted
State Implementation and Classification
Approved Date
03/08/2011
Original Release Date
25/03/2011
Nominal Hours
50
Field of Education
060301 - General Nursing
Description
DescriptorThis competency unit describes the skills and knowledge required to undertake a nursing assessment using a lifespan approachIt involves identifying normal ranges, recording and reporting processes, in routine settings in particular on client admission, ongoing and discharge
General notes
N/A
Elements and Performance Criteria
1. Collect data relating to client health
- 1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions
- 1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
- 1.3 Perform other clinical measurements/assessments such as activities of daily living
- 1.4 Document current client health practices, issues and needs
- 1.5 Document and report variations from normal on a regular basis
- 1.6 Involve client in the process of data collection wherever possible
- 1.7 Undertake ongoing data collection, such as vital signs
2. Undertake client assessment for admission and discharge
- 2.1 Collect client-based data for admission and/or discharge planning
- 2.2 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
- 2.3 Follow organisation policies and procedures relating to client participation
- 2.4 Undertake client admission with understanding of processes involved and key issues to be addressed
- 2.5 Take into account individual's values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate
- 2.6 Document client information, such as community resources, to assist in planning for discharge
- 2.7 Accurately record and report admission and discharge information
- 2.8 Respect cultural, spiritual and religious wishes during nursing assessment
3. Contribute to planning nursing care for clients in a health care environment
- 3.1 Contribute to development of nursing care plans within the context of the area of health care and implement in consultation/collaboration with the registered nurse
- 3.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice
- 3.3 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
- 3.4 Identify and implement stress management techniques for clients
4. Prepare for client discharge
- 4.1 Clarify client needs for community support services on discharge and identify appropriate community support services to the client
- 4.2 Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice
- 4.3 Ensure client has all requirements for discharge:
- next GP's appointment
- medications
- any referrals
- 4.4 Ensure documentation is completed as per policy and procedure
5. Work with clients across the life span
- 5.1 Work with an understanding of the different approaches to the concepts of growth and development
- 5.2 Work with an awareness of differing influences on human development, of genetics and environment
- 5.3 When working with clients across the life span, take into account differences in physical growth, cognitive and motor development, psychosocial development and issues associated with different stages of development
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.
Preliminary health assessment data collected may include:
Biographical information
Co-existing health problems
Allergies
Medications
Presenting condition
Past medical or surgical condition
Current lifestyle patterns and behaviours
Client and/or family concerns regarding the illness or disease
Family history of presenting illness or disease in addition to length of symptoms
Environmental factors and living circumstances
Immunisation status
Clinical nursing interventions or observations include:
Skin colour, integrity and turgor
Height and weight
Body mass index
Blood glucose level
Temperature/pulse/respirations
Blood pressure
Sensory perception
Performance of activities of daily living
Neurological observations
Urinalysis
Age and gender considerations could include:
Maturation and physical development
Self esteem
Body image perceptions
Age of consent
Need for parental consent
Confidentiality
Male health concerns
Female health concerns
Cultural, spiritual or religious data could include:
Religious beliefs
Cultural practices
Spiritual beliefs
Views on health and illness
Culturally appropriate nursing actions
Need for interpreter services
Common terms associated with human behaviour may include:
Perception
Sensation
Emotion
Motivation
Achievement
Affect
Mood
Factors that influence health related behaviour may include:
Physiological
Psychological
Economic
Educational
Geographical
Environmental
Social
Culture
Gender
Age
The concepts of growth and development may include:
Simple to complex
Cephalocaudal
Proximo-distal
Inclusive
Interdependent
Cognitive
Physical
Social
Emotional
The theorists associated with theories of growth and development may include:
Maslow
Erikson
Freud
Piaget
Havighurst
Cognitive and motor development of infants (0 - 1) may include:
Percentile charts
Reflexes
Spatial relationships
Time
Object permanence
Attachment and Bonding
Memory
Gross motor skills - Rolling, Crawling, Walking
Language development
Emotional development - from excitement to jealousy
Relationship development
Toddler's development may include:
Speech
Slow down of physical growth
Gross motor skills: walking, running, climbing, riding tricycles
Self feeding
Toilet training
Fine motor skills: pencil grip, using scissors, pulling up pants, washing hands
Object permanence developing (cont)
Toddler's development may include (Cont):
Cause and effect
Completion of simple puzzles
Assist rather than instruct
Sensitivity from adults
Safe environment
Temper tantrums
Beginnings of independence and autonomy
Play along side other children
Offering choices
Love and affection
Routines
Preschooler's development may include:
Safe environment
Physical growth increases
Gross motor skills: running, climbing, jumping, throwing, catching
Fine motor skills: cutting, painting, drawing
Egocentric
Increasing language skills : chatter, sing
Endless questioning
Pre - operational phase (Piaget)
Social interactions
Construction activities
Learning requires the use of physical materials integrated into real life situations
Playing with other children, actively looking for playmates
Development of fears: dark, accidents
Rich and creative imagination
Require acceptance and encouragement
Need for exploration with in a safe environment
Routines
School aged child's development may include:
Participation in team sports
Height, weight and changes in proportion
Permanent teeth
Appearance of secondary sexual characteristics
Timing and coordination
Injury prevention
Concrete operational phase (Piaget)
Abstract and more flexible thought
Problem solving skills
Social self
Peer group
Playground pecking order
Generosity
Cooperation
Helpfulness
Self concept
Self esteem
Independence
Recognition of individual needs
Fear, Depression and Detachment
Adolescence development may include:
Puberty
Changes in height and weight - growth spurts
Body proportions
Menstruation
Muscle development
Sexual development
Self image
Abstract thinking
Appreciation for double meanings and symbolism
Formal operation phase (Piaget)
Identity V Role confusion (Erikson)
Emancipation from parents
Formation of Personal identity
Dating - behaviour, rejection and first love
Safety, protection and support
Major adolescent issues may include:
Teenage Suicide
Substance Use and Abuse
Safe Sex
Teenage Pregnancy
Eating Disorders
Employment
Career path
Rape
Gender identity
'Generation Gap'
Juvenile Delinquency/Crime
Road Accidents
Alcohol consumption - binge drinking
Smoking
Peer pressure
Early, middle and older adult activities may include:
Finding a partner
Marriage
Developing a Career
Parent hood
Economic Independence
Death of family members
Children grow up and leave home
Contribution to society/future generations
Mentors for younger generations
Community work
Menopause
Reduction in Progesterone
Marriage disenchantment
'Empty Nest'
Retirement
Grandparenthood
Community work
Nursing record or reports may include:
Completion of client based assessment tools and observation charts
Nursing notes
Integrated notes
Resident classification records
Test results
Written instructions
Drug orders
Client referrals
Clinical pathways
Care plans
Computerised reporting
Biomedical equipment may include:
Timing device with second hand
Manual/electronic sphygmomanometer
Stethoscope
Glass/tympanic/thermometer
Pulse oximeter
Glucometer
Weighing scales
Pencil torch
Peak flow meter
ECG machine/monitor
Urine testing kit
Validations of findings include:
Visual and verbal assessment of the client
Checks/comparisons on baseline observations
Use of manual versus mechanical; observations
Elimination of artefacts
Checking of reading with a registered nurse, as appropriate
Admission and discharge may include:
Admission documentation/application of client identification
Collection of data
Care of valuables/Identification of belongings
Orientation to unit
Diet and fluids need identified
Identify and storage of current medication/s
Commence discharge plan
Return belongings and medications
Documentation of time of discharge
Appointments for follow up
Ensure transport organised
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.
Preliminary health assessment data collected may include:
Biographical information
Co-existing health problems
Allergies
Medications
Presenting condition
Past medical or surgical condition
Current lifestyle patterns and behaviours
Client and/or family concerns regarding the illness or disease
Family history of presenting illness or disease in addition to length of symptoms
Environmental factors and living circumstances
Immunisation status
Clinical nursing interventions or observations include:
Skin colour, integrity and turgor
Height and weight
Body mass index
Blood glucose level
Temperature/pulse/respirations
Blood pressure
Sensory perception
Performance of activities of daily living
Neurological observations
Urinalysis
Age and gender considerations could include:
Maturation and physical development
Self esteem
Body image perceptions
Age of consent
Need for parental consent
Confidentiality
Male health concerns
Female health concerns
Cultural, spiritual or religious data could include:
Religious beliefs
Cultural practices
Spiritual beliefs
Views on health and illness
Culturally appropriate nursing actions
Need for interpreter services
Common terms associated with human behaviour may include:
Perception
Sensation
Emotion
Motivation
Achievement
Affect
Mood
Factors that influence health related behaviour may include:
Physiological
Psychological
Economic
Educational
Geographical
Environmental
Social
Culture
Gender
Age
The concepts of growth and development may include:
Simple to complex
Cephalocaudal
Proximo-distal
Inclusive
Interdependent
Cognitive
Physical
Social
Emotional
The theorists associated with theories of growth and development may include:
Maslow
Erikson
Freud
Piaget
Havighurst
Cognitive and motor development of infants (0 - 1) may include:
Percentile charts
Reflexes
Spatial relationships
Time
Object permanence
Attachment and Bonding
Memory
Gross motor skills - Rolling, Crawling, Walking
Language development
Emotional development - from excitement to jealousy
Relationship development
Toddler's development may include:
Speech
Slow down of physical growth
Gross motor skills: walking, running, climbing, riding tricycles
Self feeding
Toilet training
Fine motor skills: pencil grip, using scissors, pulling up pants, washing hands
Object permanence developing (cont)
Toddler's development may include (Cont):
Cause and effect
Completion of simple puzzles
Assist rather than instruct
Sensitivity from adults
Safe environment
Temper tantrums
Beginnings of independence and autonomy
Play along side other children
Offering choices
Love and affection
Routines
Preschooler's development may include:
Safe environment
Physical growth increases
Gross motor skills: running, climbing, jumping, throwing, catching
Fine motor skills: cutting, painting, drawing
Egocentric
Increasing language skills : chatter, sing
Endless questioning
Pre - operational phase (Piaget)
Social interactions
Construction activities
Learning requires the use of physical materials integrated into real life situations
Playing with other children, actively looking for playmates
Development of fears: dark, accidents
Rich and creative imagination
Require acceptance and encouragement
Need for exploration with in a safe environment
Routines
School aged child's development may include:
Participation in team sports
Height, weight and changes in proportion
Permanent teeth
Appearance of secondary sexual characteristics
Timing and coordination
Injury prevention
Concrete operational phase (Piaget)
Abstract and more flexible thought
Problem solving skills
Social self
Peer group
Playground pecking order
Generosity
Cooperation
Helpfulness
Self concept
Self esteem
Independence
Recognition of individual needs
Fear, Depression and Detachment
Adolescence development may include:
Puberty
Changes in height and weight - growth spurts
Body proportions
Menstruation
Muscle development
Sexual development
Self image
Abstract thinking
Appreciation for double meanings and symbolism
Formal operation phase (Piaget)
Identity V Role confusion (Erikson)
Emancipation from parents
Formation of Personal identity
Dating - behaviour, rejection and first love
Safety, protection and support
Major adolescent issues may include:
Teenage Suicide
Substance Use and Abuse
Safe Sex
Teenage Pregnancy
Eating Disorders
Employment
Career path
Rape
Gender identity
'Generation Gap'
Juvenile Delinquency/Crime
Road Accidents
Alcohol consumption - binge drinking
Smoking
Peer pressure
Early, middle and older adult activities may include:
Finding a partner
Marriage
Developing a Career
Parent hood
Economic Independence
Death of family members
Children grow up and leave home
Contribution to society/future generations
Mentors for younger generations
Community work
Menopause
Reduction in Progesterone
Marriage disenchantment
'Empty Nest'
Retirement
Grandparenthood
Community work
Nursing record or reports may include:
Completion of client based assessment tools and observation charts
Nursing notes
Integrated notes
Resident classification records
Test results
Written instructions
Drug orders
Client referrals
Clinical pathways
Care plans
Computerised reporting
Biomedical equipment may include:
Timing device with second hand
Manual/electronic sphygmomanometer
Stethoscope
Glass/tympanic/thermometer
Pulse oximeter
Glucometer
Weighing scales
Pencil torch
Peak flow meter
ECG machine/monitor
Urine testing kit
Validations of findings include:
Visual and verbal assessment of the client
Checks/comparisons on baseline observations
Use of manual versus mechanical; observations
Elimination of artefacts
Checking of reading with a registered nurse, as appropriate
Admission and discharge may include:
Admission documentation/application of client identification
Collection of data
Care of valuables/Identification of belongings
Orientation to unit
Diet and fluids need identified
Identify and storage of current medication/s
Commence discharge plan
Return belongings and medications
Documentation of time of discharge
Appointments for follow up
Ensure transport organised
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 the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the clinical 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 and writing
Role play/simulation
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 other related nursing units and with:
HLTAP401B Confirm physical health status
HLTEN402B Communicate effectively in a nursing role
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 the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the clinical 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 and writing
Role play/simulation
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 other related nursing units and with:
HLTAP401B Confirm physical health status
HLTEN402B Communicate effectively in a nursing role
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9205 | HLTEN403A | Undertake basic client assessment | Unit of competency |
