NTISthis.com

Evidence Guide: HLTEN406B - Undertake basic wound care

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

 

HLTEN406B - Undertake basic wound care

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. Apply knowledge of physiological processes of healing
  3. Seek client cooperation and consent
  4. Maintain client privacy and dignity
  5. Utilise strategies to minimise cross-infection during assessment and implementation
  6. Identify and document level of improvement in wound healing
  7. Record data in line with organisation protocols, guidelines and procedures
  8. 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:

 

 

 

 

 

 

 

Apply knowledge of physiological processes of healing

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:

 

 

 

 

 

 

 

Identify and document level of improvement in wound healing

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:

 

 

 

 

 

 

 

Contribute to planning appropriate care for the client with a wound

  1. Discuss wound care with the client in conjunction with the registered nurse
  2. Observe evidence based principles and practice associated with wound care
  3. Take into account the sequencing, timing and client needs when planning care
  4. Take into account primary health care principles and holistic approach when planning care
  5. Utilise knowledge of physiological processes associated with normal wound healing in planning and delivering treatments
  6. Identify client comfort needs (eg. pain relief) before undertaking wound care
  7. Identify impact of wound on activities of daily living for client, in consultation/collaboration with registered nurse
  8. Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required
  9. Be aware of the potential impact of wound on client and/or family
Discuss wound care with the client in conjunction with the registered nurse

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe evidence based principles and practice associated with wound care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Take into account the sequencing, timing and client needs when planning care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Take into account primary health care principles and holistic approach when planning care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Utilise knowledge of physiological processes associated with normal wound healing in planning and delivering treatments

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify impact of wound on activities of daily living for client, in consultation/collaboration with registered nurse

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:

 

 

 

 

 

 

 

Be aware of the potential impact of wound on client and/or family

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement wound care strategies in conjunction with wound management team

  1. Collect all requirements for the procedure
  2. Maintain client privacy and dignity throughout all aspects of the procedure
  3. Observe aseptic technique for clean surgical wound
  4. Use clean techniques where appropriate for clean wounds
  5. Undertake appropriate hand washing
  6. Remove sutures, clips and drains as directed by a registered nurse
  7. Collect specimens required for microbiology/cytology as per organisation protocol
  8. Dispose of all articles including hazardous waste in line with organisation policies and procedures
  9. Complete documentation and make the client comfortable
Collect all requirements for the procedure

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain client privacy and dignity throughout all aspects of the procedure

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe aseptic technique for clean surgical wound

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use clean techniques where appropriate for clean wounds

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Undertake appropriate hand washing

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 including hazardous waste 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. Involve client in the evaluation process
  2. Ensure documentation records ongoing progress
  3. Report progress to and discuss with a registered nurse
Involve client in the evaluation process

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure documentation records ongoing progress

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Report progress to and discuss with a registered nurse

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

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

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:

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

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