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Evidence Guide: HLTEN506B - Apply principles of wound management in the clinical environment

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

HLTEN506B - Apply principles of wound management in the clinical environment

What evidence can you provide to prove your understanding of each of the following citeria?

Undertake wound assessment

  1. Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care
  2. Seek client cooperation and consent
  3. Maintain client privacy and dignity
  4. Utilise strategies to minimise cross-infection during assessment and implementation
  5. Record data in line with organisation protocols, guidelines and procedures
  6. Observe orders relating to non-disturbance of dressings
Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Seek client cooperation and consent

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain client privacy and dignity

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Utilise strategies to minimise cross-infection during assessment and implementation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record data in line with organisation protocols, guidelines and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe orders relating to non-disturbance of dressings

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess the impact of a wound on a client and/or their family

  1. Assist in performing a holistic client assessment
  2. Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound
  3. Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living
  4. Take into account the common problems and complications of wounds when assessing a wound
  5. Correctly use health terminology associated with wound care
  6. Discuss the modes of transmission of infection and the development of infection with the client, family or significant other
Assist in performing a holistic client assessment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Take into account the common problems and complications of wounds when assessing a wound

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Correctly use health terminology associated with wound care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss the modes of transmission of infection and the development of infection with the client, family or significant other

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to planning appropriate care for the client with a wound

  1. Take into account primary health care principles and holistic approach when planning care
  2. Use contemporary assessment tools accurately
  3. Access a database of wound care representatives to assist in wound care decision making
  4. Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies
  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
  6. Demonstrate an understanding of the role of the members of the wound care health team in planning wound care
  7. Discuss preventative wound care strategies with the client and/or family
  8. Identify client comfort needs (eg. pain relief) before undertaking wound care
  9. Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required
Take into account primary health care principles and holistic approach when planning care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use contemporary assessment tools accurately

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access a database of wound care representatives to assist in wound care decision making

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Demonstrate an understanding of the role of the members of the wound care health team in planning wound care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss preventative wound care strategies with the client and/or family

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify client comfort needs (eg. pain relief) before undertaking wound care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Undertake clinical nursing care to implement wound care strategies

  1. Apply an understanding of contemporary wound management strategies
  2. Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse
  3. Maintain client privacy and dignity throughout all aspects of the procedure
  4. Implement wound care strategies taking into account legislation and organisation policies and procedures
  5. Practise standard precautions in wound management to minimise the risk of infection to the client
  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
  7. Follow aseptic technique for clean surgical wound and use clean techniques where appropriate
  8. Remove sutures, clips and drains as directed by a registered nurse
  9. Collect specimens required for microbiology/ cytology as per organisation protocol
  10. Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures
  11. Complete documentation and make the client comfortable
Apply an understanding of contemporary wound management strategies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain client privacy and dignity throughout all aspects of the procedure

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement wound care strategies taking into account legislation and organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Practise standard precautions in wound management to minimise the risk of infection to the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Follow aseptic technique for clean surgical wound and use clean techniques where appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Remove sutures, clips and drains as directed by a registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Collect specimens required for microbiology/ cytology as per organisation protocol

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete documentation and make the client comfortable

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist in evaluating the outcomes of nursing actions

  1. Monitor the client's response and progress towards planned wound management goals
  2. Ensure client is involved in the evaluation process
  3. Assist in assessing the effectiveness of wound management strategies
  4. Assist in assessing the effectiveness of wound products
  5. Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse
  6. Work within a cost effective framework
  7. Evaluate, document and communicate outcomes to the appropriate members of the health care team
  8. Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology
  9. Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse
Monitor the client's response and progress towards planned wound management goals

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure client is involved in the evaluation process

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist in assessing the effectiveness of wound management strategies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist in assessing the effectiveness of wound products

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Work within a cost effective framework

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate, document and communicate outcomes to the appropriate members of the health care team

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply contemporary wound management strategies to complex or challenging wounds

  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
  2. Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team
  3. Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse
  4. Implement appropriate contemporary wound management strategies to manage complex or challenging wounds
  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. Participate in a collaborative approach to wound management with members of the health care team
  7. Identify the common problems and complications of complex and challenging wounds
Apply an understanding of the complexity of wounds encountered in the clinical environment and pathological processes of wound healing for complex or challenging wounds

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement appropriate contemporary wound management strategies to manage complex or challenging wounds

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate in a collaborative approach to wound management with members of the health care team

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify the common problems and complications of complex and challenging wounds

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

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 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

Required Skills and Knowledge

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

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