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Elements and Performance Criteria

  1. Undertake wound assessment
  2. Assess the impact of a wound on a client and/or their family
  3. Contribute to planning appropriate care for the client with a wound
  4. Undertake clinical nursing care to implement wound care strategies
  5. Assist in evaluating the outcomes of nursing actions
  6. Apply contemporary wound management strategies to complex or challenging wounds

Required Skills

This describes the essential skills and knowledge and their level required for this unit

Essential knowledge

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit manage the task and manage contingencies in the context of the identified work role

This includes knowledge of

Anatomy and physiology

medical terminology

pathophysiology

Activities of daily living

Chain of infection transmission of infection defences and immunity host factors

Community resources

Compliance with current infection control practices and guidelines

Confidentiality and privacy

Documentation principles

Educational resources and professional organisations associated with wound management

Historical development of contemporary wound management strategies

Infection control principles

Legal framework for practice

Medical conditions

Medication administration principles as appropriate to wound care eg topical

Members of health care team

Methods of identifying bacteria and common bacterial diseases

Microbiology related to

anaerobic organisms

Gram negative organisms

Gram positive

nosocomial infection

Organisation policy and procedure

Pharmocodynamics and pharmokinetics

Workplace health sand safety

Wound management terminology

Essential skills

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit manage the task and manage contingencies in the context of the identified work role

This includes the ability to

Apply infection control principles in a variety of health environments

Apply documentation principles recording and reporting abbreviations for medical terms types of data to be collected data collection instruments used in health care environments

Apply professional standards of practice

ANMC code of conduct

ANMC code of ethics

ANMC national EnrolledDivision nurse competency standards

stateterritory Nurse Regulatory Nurses Act

stateterritory Nursing and Midwifery Regulatory Authority standards of practice

scope of nursing practice decision making framework

Take into account opportunities to address waste minimisation environmental responsibility and sustainable practice issues

Undertake wound assessment

Use wound care techniques asepsis debridement packing a wound specimen collection wound cleansing

Undertake infection control risk assessment in relation to

client

others

self

Use language literacy and numeracy skills

Use communication skills questioning skills teaching skills

Evidence Required

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 but may be undertaken in a simulated clinical work environment and under the normal range of clinical environment conditions

Consistency in Performance

Observation of clinical performance

Questioning

Evidence gathered from the clinical work environment

Competency assessment tools

Case studies

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 andor Torres Strait Islander clients and communities

Related units

This unit is recommended to be assessed in conjunction with the following related units

HLTAPB Analyse health information

HLTAP501B Analyse health information

HLTINC Comply with infection control policies and procedures

HLTIN301C Comply with infection control policies and procedures

This competency unit incorporates the content of

HLTENB Undertake basic wound care

HLTEN406B Undertake basic wound care


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.

Wound management techniques include:

Wound debridement

Wound specimen collection

Interpreting laboratory results

Doppler assessment

Compression therapy

Wound cleansing techniques

Wound measurement

Clinical photography

Wound tracing

Selection of wound products include:

Range of products

Primary dressing products

Secondary dressing products

Wound cleansing products

Wound management strategies includes:

Wound management principles

Moist wound healing

Holistic assessment

Individualised wound management plan of care

Problem solving framework

Skin assessment

Risk assessment

Pressure support and relieving devices

Prevention programs

Members of health care team

Wound characteristics

Selection of wound products

Complex or challenging wounds could include:

Acute wounds

Surgical wounds

Acutely discharging wounds

Burns

Acute and/or chronic wounds include:

Surgical wounds

Pressure ulcers

Venous ulcers

Arterial ulcers

Mixed ulcers

Discharging wound

Malignant wounds

Neuropathic ulceration wounds

Infected wounds

Burns

Fistulas and sinuses

Pain management

Wound healing include:

Phases of wound healing

Modes of wound healing

Factors influencing wound healing

Moist wound healing

Role of exudate

Principles of infection control:

Nosocomial infections

Causative organisms

Principles of asepsis

Hand washing

Wounds caused by micro-organisms include:

Staphylococcus aureus - boils, wound infections

Clostridium - tetanus, gas gangrene, botulism

Proteus - wound infections

Common fungal infections include:

Tinea pedis (athlete's foot)

Tinea capitus / corporis (ringworm)

Common viral diseases may include:

herpes simplex I (cold sores)

herpes simplex II (genital herpes)

herpes zoster

Commonly seen wounds as a result of acute/chronic conditions may include:

Diabetic ulcers

Burns

Pressure (decubitus) ulcers

Tropical ulcers

Post surgical

Trauma

Harmful effects of microflora include:

Skin - pimples, carbuncles, furuncles

Mouth - gum disease, caries

Ears and eyes - otitis externa, conjunctivitis, trachoma

Components of the chain of infection:

Infective agent

Portal of entry

Portal of exit

Reservoir

Susceptible host

Mode of transmission

Wound management team may function in a variety of health care contexts and may include:

Nurses

Medical practitioners

Occupational therapists

Microbiologists

Pharmacists

Carers