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Elements and Performance Criteria

  1. Undertake wound assessment
  2. Contribute to planning appropriate care for the client with a wound
  3. Implement wound care strategies in conjunction with wound management team
  4. Assist in evaluating the outcomes of nursing actions

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

Aetiology of chronic wounds trauma venousarterial insufficiency infection

Anatomy and physiology of dermis muscle and bone and physiology of wound healing

Biohazard and waste disposal

Chain of infection transmission of infection defences and immunity host factors

Common fungi protozoa and viral diseases

Evaluation of wounds

Evidencebased practice compression therapy use of honey hyperbaric therapy

Infection prevention interventions hand washing asepsis and aseptic technique sterilisation disinfection and decontamination

Methods of identifying bacteria and common bacterial diseases

Microbiology related to nosocomial infection anaerobic organisms Gram positive and Gram negative organisms

Mode of action of antiseptics other topical solutions hydrocolloids agars antibiotics

Signs and symptoms of infection

Standard precautions compliance with current infection control practices and guidelines

Types of dressings methods of fixation

Wound management strategies and contemporary wound healing practice

Essential skills

It is critical that the candidate demonstrate the ability to

Apply knowledge of processes and protocols in the setting where care is being provided

Demonstrate understanding when advice and referral to appropriate health professional is required

Maintain aseptic or clean technique as appropriate

In addition the candidate must be able 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 Professional Standards of Practice

ANMC code of conduct

ANMC code of ethics

ANMC national EnrolledDivision nurse competency standards

scope of nursing practice decision making framework

stateterritory Nurse Regulatory Nurses Act

stateterritory Nursing and Midwifery Regulatory Authority standards of practice

Demonstrate critical thinking in the conduct of EnrolledDivision nurse practice

Demonstrate effective interpersonal skills

Maintain reporting and documentation

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

Undertake wound assessment

Use aseptic technique

Use oral communication skills language competence required to fulfil job roles as specified by the organisationservice

Use written communication skills literacy competence required to fulfil job roles as specified by organisationservice The level of skill may range from reading and understanding client documentation to completion of incident reports

Undertake infection control risk assessment in relation to

client

others

self

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

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 work place of clinical performance

Written assignmentsprojects

Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice

Questioning verbal and written

Role playsimulation

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 competency units

HLTENB Implement basic nursing care

HLTEN405B Implement basic nursing care

HLTINC Comply with infection control policies and procedures

HLTIN301C Comply with infection control policies and procedures

HLTAPB Confirm physical health status

HLTAP401B Confirm physical health status


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

Common terms associated with microbiology may include:

Commensal

Microflora

Normal flora

Pathogen

Symbiosis

Nosocomial infection

Endogenous

Exogenous

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 (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

Common terms associated with the spread of disease:

Antibiotic

Communicable

Contagious

Epidemiology

Epidemic

Endemic

Pandemic

Host

Incubation

Infectious

Acute infection

Chronic infection

Latent

Primary infection

Secondary infection

Local infection

Generalised infection

Sterilisation

Disinfection

Infection process may include:

Inflammatory process

Histamine

Kinins

Phagocytosis

Pus

Tissue repair

Wound assessment may include the following classifications:

Clean/dirty

Infected

Surgical/traumatic

Chronic/acute

Necrotic/sloughy

Granulating

Abrasions/skin tears

Incisions/lacerations

Punctures

Avulsions

Amputations

Burns

Pressure sores

Organisation protocols, guidelines, procedures include:

Occupational health and safety

Infection control

First Aid

Policies and procedures related to the workplace including understanding the work roles of all staff.

Wound healing protocols

Wound management strategies and contemporary wound healing practice

Wound care may include the use of:

Hyrocolloids

Films

Gels

Foams

Alginate

Low order dressings, such as dry dressing, adhesive dressing, wound closure tapes

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

Nurses

Medical practitioners

Occupational therapists

Microbiologists

Pharmacists

Carers