Application
The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurses and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements |
Prerequisites
Not Applicable
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
1. Undertake wound assessment | 1.1 Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care 1.2 Seek client cooperation and consent 1.3 Maintain client privacy and dignity 1.4 Utilise strategies to minimise cross-infection during assessment and implementation 1.5 Record data in line with organisation protocols, guidelines and procedures 1.6 Observe orders relating to non-disturbance of dressings |
2. Assess the impact of a wound on a client and/or their family | 2.1 Assist in performing a holistic client assessment 2.2 Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound 2.3 Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living 2.4 Take into account the common problems and complications of wounds when assessing a wound 2.5 Correctly use health terminology associated with wound care 2.6 Discuss the modes of transmission of infection and the development of infection with the client, family or significant other |
3. Contribute to planning appropriate care for the client with a wound | 3.1 Take into account primary health care principles and holistic approach when planning care 3.2 Use contemporary assessment tools accurately 3.3 Access a database of wound care representatives to assist in wound care decision making 3.4 Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies 3.5 Contribute to development of an individual wound management plan for the client in consultation/collaboration with the client and the health care team, including a registered nurse 3.6 Demonstrate an understanding of the role of the members of the wound care health team in planning wound care 3.7 Discuss preventative wound care strategies with the client and/or family 3.8 Identify client comfort needs (eg. pain relief) before undertaking wound care 3.9 Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required |
4. Undertake clinical nursing care to implement wound care strategies | 4.1 Apply an understanding of contemporary wound management strategies 4.2 Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse 4.3 Maintain client privacy and dignity throughout all aspects of the procedure 4.4 Implement wound care strategies taking into account legislation and organisation policies and procedures 4.5 Practise standard precautions in wound management to minimise the risk of infection to the client 4.6 In consultation/collaboration with the health care team, utilise wound management products and techniques appropriate to the identified phase of wound healing and collect all resources required for the procedure 4.7 Follow aseptic technique for clean surgical wound and use clean techniques where appropriate 4.8 Remove sutures, clips and drains as directed by a registered nurse 4.9 Collect specimens required for microbiology/ cytology as per organisation protocol 4.10 Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures 4.11 Complete documentation and make the client comfortable |
5. Assist in evaluating the outcomes of nursing actions | 5.1 Monitor the client's response and progress towards planned wound management goals 5.2 Ensure client is involved in the evaluation process 5.3 Assist in assessing the effectiveness of wound management strategies 5.4 Assist in assessing the effectiveness of wound products 5.5 Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse 5.6 Work within a cost effective framework 5.7 Evaluate, document and communicate outcomes to the appropriate members of the health care team 5.8 Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology 5.9 Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse |
6. Apply contemporary wound management strategies to complex or challenging wounds | 6.1 Apply an understanding of the complexity of wounds encountered in the clinical environment and pathological processes of wound healing for complex or challenging wounds 6.2 Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team 6.3 Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse 6.4 Implement appropriate contemporary wound management strategies to manage complex or challenging wounds 6.5 Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse 6.6 Participate in a collaborative approach to wound management with members of the health care team 6.7 Identify the common problems and complications of complex and 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 Enrolled/Division 2 nurse competency standards state/territory Nurse Regulatory Nurses Act state/territory 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 and/or Torres Strait Islander clients and communities |
Related units: | This unit is recommended to be assessed in conjunction with the following related units: HLTAP501B Analyse health information HLTIN301C Comply with infection control policies and procedures This competency unit incorporates the content of: 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 |
Sectors
Not Applicable
Employability Skills
This unit contains Employability Skills |
Licensing Information
Not Applicable