HLTEN506B - Apply principles of wound management in the clinical environment Competency Mapping Template
Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners
HLTEN506B Mapping and Delivery Guide Apply principles of wound management in the clinical environment
Version 1.0 Issue Date: May 2024
Qualification
-
Unit of Competency
HLTEN506B - Apply principles of wound management in the clinical environment
Description
Enrolled/Division 2 nurses apply contemporary wound management principles to the care of clients with varying types of wounds
Employability Skills
This unit contains Employability Skills
Learning Outcomes and Application
The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirementsEnrolled/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
Duration and Setting
X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.
Prerequisites/co-requisites
Not Applicable
Competency Field
Development and validation strategy and guide for assessors and learners
Student Learning Resources
Handouts Activities
Slides PPT
Assessment 1
Assessment 2
Assessment 3
Assessment 4
Elements of Competency
Performance Criteria
Element: Undertake wound assessment
Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care
Seek client cooperation and consent
Maintain client privacy and dignity
Utilise strategies to minimise cross-infection during assessment and implementation
Record data in line with organisation protocols, guidelines and procedures
Observe orders relating to non-disturbance of dressings
Element: Assess the impact of a wound on a client and/or their family
Assist in performing a holistic client assessment
Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound
Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living
Take into account the common problems and complications of wounds when assessing a wound
Correctly use health terminology associated with wound care
Discuss the modes of transmission of infection and the development of infection with the client, family or significant other
Element: Contribute to planning appropriate care for the client with a wound
Take into account primary health care principles and holistic approach when planning care
Use contemporary assessment tools accurately
Access a database of wound care representatives to assist in wound care decision making
Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies
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
Demonstrate an understanding of the role of the members of the wound care health team in planning wound care
Discuss preventative wound care strategies with the client and/or family
Identify client comfort needs (eg. pain relief) before undertaking wound care
Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required
Element: Undertake clinical nursing care to implement wound care strategies
Apply an understanding of contemporary wound management strategies
Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse
Maintain client privacy and dignity throughout all aspects of the procedure
Implement wound care strategies taking into account legislation and organisation policies and procedures
Practise standard precautions in wound management to minimise the risk of infection to the client
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
Follow aseptic technique for clean surgical wound and use clean techniques where appropriate
Remove sutures, clips and drains as directed by a registered nurse
Collect specimens required for microbiology/ cytology as per organisation protocol
Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures
Complete documentation and make the client comfortable
Element: Assist in evaluating the outcomes of nursing actions
Monitor the client's response and progress towards planned wound management goals
Ensure client is involved in the evaluation process
Assist in assessing the effectiveness of wound management strategies
Assist in assessing the effectiveness of wound products
Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse
Work within a cost effective framework
Evaluate, document and communicate outcomes to the appropriate members of the health care team
Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology
Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse
Element: Apply contemporary wound management strategies to complex or 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
Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team
Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse
Implement appropriate contemporary wound management strategies to manage complex or challenging wounds
Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse
Participate in a collaborative approach to wound management with members of the health care team
Identify the common problems and complications of complex and challenging wounds
Evidence Required
List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.
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:
List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, checklist) and due date here
Assessment task 1: [title] Due date:
(add new lines for each of the assessment tasks)
Assessment Tasks
Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.
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
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
Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.
Observation Checklist
Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice
Yes
No
Comments/feedback
Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care
Seek client cooperation and consent
Maintain client privacy and dignity
Utilise strategies to minimise cross-infection during assessment and implementation
Record data in line with organisation protocols, guidelines and procedures
Observe orders relating to non-disturbance of dressings
Assist in performing a holistic client assessment
Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound
Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living
Take into account the common problems and complications of wounds when assessing a wound
Correctly use health terminology associated with wound care
Discuss the modes of transmission of infection and the development of infection with the client, family or significant other
Take into account primary health care principles and holistic approach when planning care
Use contemporary assessment tools accurately
Access a database of wound care representatives to assist in wound care decision making
Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies
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
Demonstrate an understanding of the role of the members of the wound care health team in planning wound care
Discuss preventative wound care strategies with the client and/or family
Identify client comfort needs (eg. pain relief) before undertaking wound care
Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required
Apply an understanding of contemporary wound management strategies
Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse
Maintain client privacy and dignity throughout all aspects of the procedure
Implement wound care strategies taking into account legislation and organisation policies and procedures
Practise standard precautions in wound management to minimise the risk of infection to the client
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
Follow aseptic technique for clean surgical wound and use clean techniques where appropriate
Remove sutures, clips and drains as directed by a registered nurse
Collect specimens required for microbiology/ cytology as per organisation protocol
Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures
Complete documentation and make the client comfortable
Monitor the client's response and progress towards planned wound management goals
Ensure client is involved in the evaluation process
Assist in assessing the effectiveness of wound management strategies
Assist in assessing the effectiveness of wound products
Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse
Work within a cost effective framework
Evaluate, document and communicate outcomes to the appropriate members of the health care team
Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology
Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse
Apply an understanding of the complexity of wounds encountered in the clinical environment and pathological processes of wound healing for complex or challenging wounds
Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team
Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse
Implement appropriate contemporary wound management strategies to manage complex or challenging wounds
Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse
Participate in a collaborative approach to wound management with members of the health care team
Identify the common problems and complications of complex and challenging wounds
Forms
Assessment Cover Sheet
HLTEN506B - Apply principles of wound management in the clinical environment
Assessment task 1: [title]
Student name:
Student ID:
I declare that the assessment tasks submitted for this unit are my own work.
Student signature:
Result: Competent Not yet competent
Feedback to student
Assessor name:
Signature:
Date:
Assessment Record Sheet
HLTEN506B - Apply principles of wound management in the clinical environment
Student name:
Student ID:
Assessment task 1: [title] Result: Competent Not yet competent
(add lines for each task)
Feedback to student:
Overall assessment result: Competent Not yet competent