Unit of competency Outline
Information current as of
21/10/2026 2:04 AM AWST
21/10/2026 2:04 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.
Implement basic nursing care
Implement basic nursing care
Unit of competency
National Code
HLTEN405B
HLTEN405B
State Code
D8200
D8200
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
60
Field of Education
060301 - General Nursing
Description
DescriptorThis unit describes the skills and knowledge required to contribute to the nursing care of clients in a range of health environments
General notes
N/A
Elements and Performance Criteria
1. Establish and maintain therapeutic relationships with clients
- 1.1 Provide appropriate introductions and explanations prior to all nursing interventions
- 1.2 Identify and use appropriate language and interpersonal skills to ensure that the diverse needs of clients and health care settings
- 1.3 Conduct the client advocate role within the Enrolled/Division 2 nurse's scope of practice
- 1.4 Work effectively with clients from a range of cultural, spiritual and religious backgrounds, taking action to address cultural factors that may impact on nursing practice
- 1.5 Demonstrate responsibility and accountability for implementing nursing care within the Enrolled/Division 2 Nurse scope of practice
2. Identify client needs relating to individualised nursing care
- 2.1 Identify actual and potential nursing care needs in consultation/collaboration with the client
- 2.2 Identify situations of risk or potential risk and implement risk prevention/minimisation strategies and refer to registered nurse as appropriate
- 2.3 Identify client needs for health education and implement education within scope of nursing practice and in consultation/collaboration with registered nurse
- 2.4 Identify client nutritional needs in consultation/ collaboration with client and their significant others
3. Assist clients in activities of daily living
- 3.1 Explain to client the importance of hygiene and grooming to achieving health outcomes
- 3.2 Assist clients to address hygiene, dressing and grooming needs
- 3.3 Describe conditions which affect the oral cavity and demonstrate effective oral hygiene to client
- 3.4 Assist clients with their diet and fluid intake and ensure client's nutritional needs are met in consultation/collaboration with registered nurse
- 3.5 Apply strategies to assist clients with diet and fluid intake
- 3.6 Recognise and manage emergency situations associated with diet and fluid intake
- 3.7 Assist clients with key aspects of elimination
- 3.8 Explain and demonstrate to clients key factors associated with fluid balance and bowel charts
- 3.9 Assist with respiratory function especially deep breathing and coughing exercises
- 3.10 Use appropriate measures to promote comfort, rest and sleep
4. Assist with movement of clients
- 4.1 Apply the principles and techniques of safe manual handling when assisting clients with movement
- 4.2 Actively encourage clients to contribute to their own mobility
- 4.3 Implement the principles of 'no-lift' policy when assisting clients with movement
- 4.4 Assist clients to safely transfer using appropriate mobility procedures with reference to safety of self, client and others involved
- 4.5 Identify and describe to clients factors contributing to the formation of decubitus ulcers
- 4.6 Apply practices to avoid breakdown of pressure areas
- 4.7 Identify common pressure area sites with reference to the needs of each individual client
- 4.8 Use and explain appropriate strategies to prevent and manage decubitus ulcers
5. Prepare clients for procedures
- 5.1 Provide each client with a full explanation regarding preparation for specific procedures
- 5.2 Incorporate health teaching into practice within role responsibility
- 5.3 Maintain privacy and dignity of client throughout
- 5.4 Complete documentation as per organisation policy and procedures
- 5.5 Observe validity of consent and report any concerns to the registered nurse, as appropriate
6. Contribute to nursing care in consultation/ collaboration with registered nurse
- 6.1 Participate in the implementation of a plan of nursing care in line with duty of care and Occupational Health and Safety policies and procedures
- 6.2 Identify and apply safe work place procedures as per OH&S policies and organisation policies and procedures
- 6.3 Identify and apply infection control principles in all work activities
- 6.4 Prioritise work activities to meet acuity of client needs in consultation/collaboration with a registered nurse
- 6.5 Work in a manner that maintains the client's privacy and dignity and demonstrates best practice based on a full range of relevant information including scientific rationale
- 6.6 Undertake nursing procedures as delegated within the nursing team and scope of practice in consultation/collaboration with a registered nurse
- 6.7 Apply strategies to promote comfort, rest and sleep
- 6.8 Assist with the implementation of appropriate nursing actions to prevent and manage decubitus ulcers in consultation/collaboration with a registered nurse
- 6.9 Implement appropriate action to address urgent needs in consultation/collaboration with a registered nurse and document and report as appropriate
- 6.10 Maintain documentation and reporting requirements as per organisation policies and procedures
7. Monitor and evaluate clients during care
- 7.1 Maintain ongoing observation and assessment during nursing care
- 7.2 Observe and document changes in client independence or pain tolerance within scope of Enrolled/Division 2 Nurse practice
- 7.3 Record and report changes in condition/baseline data/behaviour to the registered nurse, as appropriate
- 7.4 Document evidence of client outcomes in nursing care plan
- 7.5 Respond to and report situations of risk to registered nurse
- 7.6 Identify and respond appropriately to signs and symptoms of common emergency situations
- 7.7 Demonstrate respect for the client's attitudes and values in regard to resuscitation
- 7.8 Use emergency codes correctly
- 7.9 Initiate CPR according to organisation procedures
8. Evaluate own contribution to nursing care
- 8.1 Evaluate nursing care in consultation/collaboration with the client and the multidisciplinary team
- 8.2 Evaluate nursing care in light of client outcomes
- 8.3 Document and report all aspects of client care provided by self
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
Therapeutic relationships include:
Nurse/client
Nurse/significant other
Client/client
Nurse/nurse
Nurse/multidisciplinary health care team
Actual and potential nursing care that clients may need assistance with:
Hygiene and toileting
Elimination/incontinence
Physical comfort
Sleep disturbances
Health education
Oral/dental care
Immobility
Respiration and circulation
Fluid and nutritional deficits
Pain
Wounds - acute and chronic
Stress
Underlying medical condition
Social emotional and financial issues
Sensory deficits
Cognitive deficits
Risks or potential risks due to hospitalisation/medical treatment may include:
Adverse reactions
Shock/haemorrhage
Deep vein thrombosis/pulmonary embolism
Nosocomial infection
Skin tears/pressure ulcer formation
Constipation
Loss of muscle tone
Slips and falls
Social isolation
Sleep deprivation
Challenging behaviour
Refusal of treatment
Workplace harassment and aggression and violence
Risk prevention strategies:
Recording of allergies
Monitoring of client vital sign
Other monitoring as required eg. fluid balance, blood sugar levels
Pressure area care
Anti-emboli stockings/DVT prophylaxis
Aseptic technique/standard precautions
Passive and active exercises
Bed rails
Assistance with transferring
The broad principles of manual handling may include:
Body mechanics
Organisation policy and procedures
Risk minimisation and 'no-lift' policies
Back care
Ergonomics
State/territory Occupational Health and Safety Act
Safe operation of equipment
Manual handling techniques must include:
Transferring a client from bed to chair and vice versa
Assisting a client to ambulate
Moving a client in the bed
Client falls
Factors contributing to mobility may include:
Client health status
Active and passive exercises
Equipment availability
Culture
Environment
Transfer/mobility devices/equipment may include:
Hoist
Wheelchairs
Walking frames
Slide sheets
Walking aids
Purpose of hygiene and grooming may include:
Cleanliness
Assessment of skin
Self esteem
Social aspects
Hygiene may include:
Showing and showering trolley
Bed bath/sponge
Bath
Grooming may include:
Brushing hair
Facial shavings
Nail care
Cleaning and applying glasses
Cleaning and inserting hearing aid
Application of make up and jewellery
Application of prostheses and orthoses
Conditions of the oral cavity may include:
Dry mouth, gums and tongue
Halitosis
Pale or bleeding mucosa and gums including tongue
Candida albicans (thrush)
Herpes Simplex/cold sores
Ulcers of the mucosa, gums and tongue
Ill fitting dentures
Deviations of tongue alignment
Stomatitis/Gingivitis
Cleft palate/lip
Dental caries
Oral hygiene may include:
Brushing teeth
Mouth wash/gargle
Mouth toilet
Application of lip emollient
Key aspects of assisting a client with diet and fluid intake may include:
Comfort
Hygiene and elimination needs are met
Serviette provided/presentation of meal
Meal size and food preference
Placement of meal to facilitate appetite
Suitable utensils and condiments offered
Rate of eating and fluids offered
Encourage independence
Meal completion, hygiene and comfort needs are met
Visual and hearing impairment considered
Swallowing impairment
Cognitive and physical impairment
Fasting and restricted fluids
Strategies to assist may include:
Position and environment
Key aspects of elimination may include:
Bedpan/Urinal/Commode
Enemas/Suppositories
Perineal care
Continence aids
Privacy and dignity
Positioning and hygiene
Disposal of waste
Odour control
Key factors associated with fluid balance and bowel charts may include:
Intake and output measurements in millilitres, totalled with positive/negative balance calculated on fluid balance chart
Diet intake chart
Accurate and continuous documentation
Description of stool on bowel chart
Report variances as per environmental policies
Factors contributing to formation of decubitus ulcers may include:
Intrinsic
Extrinsic
Strategies for prevention and management of decubitus ulcers may include:
Pressure risk assessment scales
Use of pressure relieving devices
Regular observation of skin condition\
Repositioning
Rest may include:
Power naps/meditation/relaxation techniques
Factors that promote and impede comfort, rest and sleep may include:
Routine and position
Environment/equipment
Emotional state/pain physical state
Medication
Nursing interventions
Visitors/other clients
Bed making may include:
Occupied
Unoccupied
Risk minimisation strategies for nurses may include:
Hazard assessment/reporting/risk minimisation
Implementation of 'No-Lift' policy
Maintenance of regular contact with members of the care team/nurse supervisor
Referral of self appropriately for debriefing/counselling
Attention to own health and rest requirements
Strategies for addressing workplace harassment/aggression and violence
Recording and reporting requirements includes:
Admission and discharge documentation
Client progress notes
Fluid balance charts
Conscious/neurological observations
Specific charting as required
Verbal handovers/case meetings
Critical incident reporting to senior staff
Incident reports
Understanding of work roles of other health team members
Occupational health and safety hazard reporting
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance
Therapeutic relationships include:
Nurse/client
Nurse/significant other
Client/client
Nurse/nurse
Nurse/multidisciplinary health care team
Actual and potential nursing care that clients may need assistance with:
Hygiene and toileting
Elimination/incontinence
Physical comfort
Sleep disturbances
Health education
Oral/dental care
Immobility
Respiration and circulation
Fluid and nutritional deficits
Pain
Wounds - acute and chronic
Stress
Underlying medical condition
Social emotional and financial issues
Sensory deficits
Cognitive deficits
Risks or potential risks due to hospitalisation/medical treatment may include:
Adverse reactions
Shock/haemorrhage
Deep vein thrombosis/pulmonary embolism
Nosocomial infection
Skin tears/pressure ulcer formation
Constipation
Loss of muscle tone
Slips and falls
Social isolation
Sleep deprivation
Challenging behaviour
Refusal of treatment
Workplace harassment and aggression and violence
Risk prevention strategies:
Recording of allergies
Monitoring of client vital sign
Other monitoring as required eg. fluid balance, blood sugar levels
Pressure area care
Anti-emboli stockings/DVT prophylaxis
Aseptic technique/standard precautions
Passive and active exercises
Bed rails
Assistance with transferring
The broad principles of manual handling may include:
Body mechanics
Organisation policy and procedures
Risk minimisation and 'no-lift' policies
Back care
Ergonomics
State/territory Occupational Health and Safety Act
Safe operation of equipment
Manual handling techniques must include:
Transferring a client from bed to chair and vice versa
Assisting a client to ambulate
Moving a client in the bed
Client falls
Factors contributing to mobility may include:
Client health status
Active and passive exercises
Equipment availability
Culture
Environment
Transfer/mobility devices/equipment may include:
Hoist
Wheelchairs
Walking frames
Slide sheets
Walking aids
Purpose of hygiene and grooming may include:
Cleanliness
Assessment of skin
Self esteem
Social aspects
Hygiene may include:
Showing and showering trolley
Bed bath/sponge
Bath
Grooming may include:
Brushing hair
Facial shavings
Nail care
Cleaning and applying glasses
Cleaning and inserting hearing aid
Application of make up and jewellery
Application of prostheses and orthoses
Conditions of the oral cavity may include:
Dry mouth, gums and tongue
Halitosis
Pale or bleeding mucosa and gums including tongue
Candida albicans (thrush)
Herpes Simplex/cold sores
Ulcers of the mucosa, gums and tongue
Ill fitting dentures
Deviations of tongue alignment
Stomatitis/Gingivitis
Cleft palate/lip
Dental caries
Oral hygiene may include:
Brushing teeth
Mouth wash/gargle
Mouth toilet
Application of lip emollient
Key aspects of assisting a client with diet and fluid intake may include:
Comfort
Hygiene and elimination needs are met
Serviette provided/presentation of meal
Meal size and food preference
Placement of meal to facilitate appetite
Suitable utensils and condiments offered
Rate of eating and fluids offered
Encourage independence
Meal completion, hygiene and comfort needs are met
Visual and hearing impairment considered
Swallowing impairment
Cognitive and physical impairment
Fasting and restricted fluids
Strategies to assist may include:
Position and environment
Key aspects of elimination may include:
Bedpan/Urinal/Commode
Enemas/Suppositories
Perineal care
Continence aids
Privacy and dignity
Positioning and hygiene
Disposal of waste
Odour control
Key factors associated with fluid balance and bowel charts may include:
Intake and output measurements in millilitres, totalled with positive/negative balance calculated on fluid balance chart
Diet intake chart
Accurate and continuous documentation
Description of stool on bowel chart
Report variances as per environmental policies
Factors contributing to formation of decubitus ulcers may include:
Intrinsic
Extrinsic
Strategies for prevention and management of decubitus ulcers may include:
Pressure risk assessment scales
Use of pressure relieving devices
Regular observation of skin condition\
Repositioning
Rest may include:
Power naps/meditation/relaxation techniques
Factors that promote and impede comfort, rest and sleep may include:
Routine and position
Environment/equipment
Emotional state/pain physical state
Medication
Nursing interventions
Visitors/other clients
Bed making may include:
Occupied
Unoccupied
Risk minimisation strategies for nurses may include:
Hazard assessment/reporting/risk minimisation
Implementation of 'No-Lift' policy
Maintenance of regular contact with members of the care team/nurse supervisor
Referral of self appropriately for debriefing/counselling
Attention to own health and rest requirements
Strategies for addressing workplace harassment/aggression and violence
Recording and reporting requirements includes:
Admission and discharge documentation
Client progress notes
Fluid balance charts
Conscious/neurological observations
Specific charting as required
Verbal handovers/case meetings
Critical incident reporting to senior staff
Incident reports
Understanding of work roles of other health team members
Occupational health and safety hazard reporting
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 following assessment in simulation laboratory
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, prior to assessment in the workplace
Method of assessment
Observation in the work place of clinical performance
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning verbal and written
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 units:
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 following assessment in simulation laboratory
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, prior to assessment in the workplace
Method of assessment
Observation in the work place of clinical performance
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning verbal and written
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 units:
HLTAP401B Confirm physical health status
HLTEN402B Communicate effectively in a nursing role
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9206 | HLTEN405A | Implement basic nursing care | Unit of competency |
