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 |
Not Applicable
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 Apply knowledge of physiological processes of healing 1.3 Seek client cooperation and consent 1.4 Maintain client privacy and dignity 1.5 Utilise strategies to minimise cross-infection during assessment and implementation 1.6 Identify and document level of improvement in wound healing 1.7 Record data in line with organisation protocols, guidelines and procedures 1.8 Observe orders relating to non-disturbance of dressings |
2. Contribute to planning appropriate care for the client with a wound | 2.1 Discuss wound care with the client in conjunction with the registered nurse 2.2 Observe evidence based principles and practice associated with wound care 2.3 Take into account the sequencing, timing and client needs when planning care 2.4 Take into account primary health care principles and holistic approach when planning care 2.5 Utilise knowledge of physiological processes associated with normal wound healing in planning and delivering treatments 2.6 Identify client comfort needs (eg. pain relief) before undertaking wound care 2.7 Identify impact of wound on activities of daily living for client, in consultation/collaboration with registered nurse 2.8 Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required 2.9 Be aware of the potential impact of wound on client and/or family |
3. Implement wound care strategies in conjunction with wound management team | 3.1 Collect all requirements for the procedure 3.2 Maintain client privacy and dignity throughout all aspects of the procedure 3.3 Observe aseptic technique for clean surgical wound 3.4 Use clean techniques where appropriate for clean wounds 3.5 Undertake appropriate hand washing 3.6 Remove sutures, clips and drains as directed by a registered nurse 3.7 Collect specimens required for microbiology/cytology as per organisation protocol 3.8 Dispose of all articles including hazardous waste in line with organisation policies and procedures 3.9 Complete documentation and make the client comfortable |
4. Assist in evaluating the outcomes of nursing actions | 4.1 Involve client in the evaluation process 4.2 Ensure documentation records ongoing progress 4.3 Report progress to and discuss with a registered nurse |
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, venous/arterial 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 Evidence-based 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 Enrolled/Division 2 nurse competency standards scope of nursing practice decision making framework state/territory Nurse Regulatory Nurses Act state/territory Nursing and Midwifery Regulatory Authority standards of practice Demonstrate critical thinking in the conduct of Enrolled/Division 2 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 organisation/service. Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation/service. 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 |
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 assignments/projects Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Questioning verbal and written Role play/simulation |
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 competency units: HLTEN405B Implement basic nursing care HLTIN301C Comply with infection control policies and procedures HLTAP401B Confirm physical health status |
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 |
Not Applicable
This unit contains Employability Skills |
Not Applicable