Application
This unit describes the skills and knowledge required to apply contemporary wound management principles to the care of various types of wounds. It involves working with the interdisciplinary health care team to contribute to assessment, treatment and ongoing management of a person’s wounds.
This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
Elements define the essential outcomes | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Apply protocols for wound assessment. | 1.1 Use appropriate medical terminology when assessing, reporting and recording data on wounds. 1.2 Use strategies to minimise cross-infection during assessment and implementation of wound management strategies. 1.3 Observe orders and instructions relating to non-disturbance of dressings. |
2. Assess impact of wound on a person, family or carer. | 2.1 Assist in performing holistic assessment of the person with a wound. 2.2 Apply knowledge of the physiological and biochemical processes associated with normal wound healing when assessing the person’s wound. 2.3 Consider factors that impact on wound healing, including psychosocial impact of a wound on the person’s daily living activities. 2.4 Consider common problems and complications of wounds when assessing the person’s wound. 2.5 Discuss modes of transmission of infection and infection development with the person, family or carer. |
3. Contribute to planning care for a person with a wound. | 3.1 Consider primary health care principles and holistic approaches when planning care for the person with a wound. 3.2 Access wound care experts to assist in decision-making for wound care management. 3.3 Maintain current knowledge and use an evidence-based and problem-solving approach in contributing to analysis and planning of appropriate wound care management strategies. 3.4 Contribute to an individual wound management plan for the person in consultation and collaboration with the person, registered nurse and the interdisciplinary health care team. 3.5 Discuss preventative wound care strategies with the person, family or carer. 3.6 Identify the person’s comfort needs such as pain relief in consultation with registered nurse before undertaking wound care. |
4. Undertake clinical nursing care in implementing wound care strategies. | 4.1 Use contemporary assessment tools accurately. 4.2 Implement wound care strategies, taking into account legislation and organisation policy and procedures. 4.3 In consultation and collaboration with the interdisciplinary health care team, identify wound management products and techniques appropriate to the identified phase of wound healing, and collect all resources required for the procedure. 4.4 Collect specimens required for microbiology and cytology according to organisation policy and procedures. 4.5 Dispose of all articles including hazardous waste appropriately according to organisation policy and procedures. 4.6 Make the person comfortable, and complete required documentation. |
5. Apply contemporary wound management strategies to complex or challenging wounds. | 5.1 Apply knowledge of wound complexity and the pathological processes of wound healing for complex or challenging wounds 5.2 Identify common problems and complications of complex and challenging wounds. 5.3 Follow aseptic technique for a clean surgical wound and use infection prevention techniques appropriate to the type of wound. 5.4 Remove sutures, clips and drains from a person and replace wound drainage bag as directed by a registered nurse. 5.5 Implement appropriate contemporary wound management strategies to manage the person’s complex or challenging wounds. 5.6 Participate with the interdisciplinary health care team in making an assessment of the person with a complex or challenging wound within an holistic framework. 5.7 Create and review individualised plans of care for the person with a complex or challenging wound. |
6. Assist in evaluating outcomes of nursing actions. | 6.1 Ensure involvement of the person in the evaluation process. 6.2 Monitor the person’s response to wound management strategies, and their progress towards planned wound management goals. 6.3 Evaluate, document and communicate progress of wound healing and wound care strategy outcomes to the appropriate members of the interdisciplinary health care team using contemporary terminology. 6.4 Assist in assessing effectiveness of the person’s wound management strategies and products used. 6.5 Modify wound management strategies, procedures and goals for the individual person. 6.6 Work within a cost effective framework. 6.7 Identify and plan health education and promotion strategies for the person in consultation and collaboration with the registered nurse. |
Evidence of Performance
The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:
undertaken nursing work in accordance with Nursing and Midwifery Board of Australia professional practice standards, codes and guidelines
performed wound care management, including wound assessment, health education and evaluation of the person’s wound care in the workplace on 3 wounds, of which at least 1 must involve a simple wound dressing and at least 1 must involve a complex wound dressing.
Evidence of Knowledge
The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:
National Safety and Quality Health Service (NSQHS) Standards
chain of infection
infection transmission
defences
immunity and host factors
compliance with current infection control practices and guidelines
community and educational resources and professional organisations associated with wound management
historical development of contemporary wound management strategies
pain management and medication administration timeframes appropriate to wound care
causes of wounds:
micro-organisms
common fungal infections
common viral infections
organisation policy and procedures for wound care
wound management terminology
wound management techniques including:
wound debridement
wound drains and wound drainage systems
wound specimen collection
interpreting laboratory results in consultation with registered nurse or interdisciplinary team
doppler assessment
compression therapy
wound cleansing techniques
wound measurement
clinical photography
wound tracing
acute and chronic wounds including:
surgical wounds
pressure ulcers
venous ulcers
arterial ulcers
mixed ulcers
discharging wounds
malignant wounds
neuropathic ulceration wounds
infected wounds
burns
fistulas and sinuses
skin grafts
visceral wounds
wound management strategies including:
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
wound characteristics
visceral wound management
selection of wound products including:
primary dressing
secondary dressing
wound cleansing
comfort needs of people with wounds such as the need for pain management and relief.
Assessment Conditions
Skills must have been demonstrated in the workplace or in a simulated environment as specified in the performance evidence. The following conditions must be met for this unit:
use of suitable facilities, equipment and resources in line with the Australian Nursing and Midwifery Accreditation Council’s Standards including:
wound care manikins
wound care products
dressing packs
standard precautions and personal protective equipment (PPE)
information and documentation such as wound care plans on which the candidate bases the planning process
modelling of industry operating conditions including access to real people for simulations and scenarios in enrolled nursing work.
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.
In addition, assessors must hold current registration as a registered nurse with Nursing and Midwifery Board of Australia.
Foundation Skills
The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance.
Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.