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Evidence Guide: HLTENN006 - Apply principles of wound management in the clinical environment

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!

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HLTENN006 - Apply principles of wound management in the clinical environment

What evidence can you provide to prove your understanding of each of the following citeria?

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply protocols for wound assessment.

  1. Use appropriate medical terminology when assessing, reporting and recording data on wounds.
  2. Use strategies to minimise cross-infection during assessment and implementation of wound management strategies.
  3. Observe orders and instructions relating to non-disturbance of dressings.
Use appropriate medical terminology when assessing, reporting and recording data on wounds.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use strategies to minimise cross-infection during assessment and implementation of wound management strategies.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Observe orders and instructions relating to non-disturbance of dressings.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess impact of wound on a person, family or carer.

  1. Assist in performing holistic assessment of the person with a wound.
  2. Apply knowledge of the physiological and biochemical processes associated with normal wound healing when assessing the person’s wound.
  3. Consider factors that impact on wound healing, including psychosocial impact of a wound on the person’s daily living activities.
  4. Consider common problems and complications of wounds when assessing the person’s wound.
  5. Discuss modes of transmission of infection and infection development with the person, family or carer.
Assist in performing holistic assessment of the person with a wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply knowledge of the physiological and biochemical processes associated with normal wound healing when assessing the person’s wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consider factors that impact on wound healing, including psychosocial impact of a wound on the person’s daily living activities.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consider common problems and complications of wounds when assessing the person’s wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss modes of transmission of infection and infection development with the person, family or carer.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Contribute to planning care for a person with a wound.

  1. Consider primary health care principles and holistic approaches when planning care for the person with a wound.
  2. Access wound care experts to assist in decision-making for wound care management.
  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.
  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.
  5. Discuss preventative wound care strategies with the person, family or carer.
  6. Identify the person’s comfort needs such as pain relief in consultation with registered nurse before undertaking wound care.
Consider primary health care principles and holistic approaches when planning care for the person with a wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access wound care experts to assist in decision-making for wound care management.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain current knowledge and use an evidence-based and problem-solving approach in contributing to analysis and planning of appropriate wound care management strategies.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss preventative wound care strategies with the person, family or carer.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify the person’s comfort needs such as pain relief in consultation with registered nurse before undertaking wound care.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Undertake clinical nursing care in implementing wound care strategies.

  1. Use contemporary assessment tools accurately.
  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. Collect specimens required for microbiology and cytology according to organisation policy and procedures.
  5. Dispose of all articles including hazardous waste appropriately according to organisation policy and procedures.
  6. Make the person comfortable, and complete required documentation.
Use contemporary assessment tools accurately.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Collect specimens required for microbiology and cytology according to organisation policy and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Dispose of all articles including hazardous waste appropriately according to organisation policy and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make the person comfortable, and complete required documentation.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply contemporary wound management strategies to complex or challenging wounds.

  1. Apply knowledge of wound complexity and the pathological processes of wound healing for complex or challenging wounds
  2. Identify common problems and complications of complex and challenging wounds.
  3. Follow aseptic technique for a clean surgical wound and use infection prevention techniques appropriate to the type of wound.
  4. Remove sutures, clips and drains from a person and replace wound drainage bag as directed by a registered nurse.
  5. Implement appropriate contemporary wound management strategies to manage the person’s complex or challenging wounds.
  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.
  7. Create and review individualised plans of care for the person with a complex or challenging wound.
Apply knowledge of wound complexity and the pathological processes of wound healing for complex or challenging wounds

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify common problems and complications of complex and challenging wounds.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Follow aseptic technique for a clean surgical wound and use infection prevention techniques appropriate to the type of wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Remove sutures, clips and drains from a person and replace wound drainage bag as directed by a registered nurse.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement appropriate contemporary wound management strategies to manage the person’s complex or challenging wounds.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate with the interdisciplinary health care team in making an assessment of the person with a complex or challenging wound within an holistic framework.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Create and review individualised plans of care for the person with a complex or challenging wound.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist in evaluating outcomes of nursing actions.

  1. Ensure involvement of the person in the evaluation process.
  2. Monitor the person’s response to wound management strategies, and their progress towards planned wound management goals.
  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.
  4. Assist in assessing effectiveness of the person’s wound management strategies and products used.
  5. Modify wound management strategies, procedures and goals for the individual person.
  6. Work within a cost effective framework.
  7. Identify and plan health education and promotion strategies for the person in consultation and collaboration with the registered nurse.
Ensure involvement of the person in the evaluation process.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor the person’s response to wound management strategies, and their progress towards planned wound management goals.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assist in assessing effectiveness of the person’s wound management strategies and products used.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Modify wound management strategies, procedures and goals for the individual person.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Work within a cost effective framework.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and plan health education and promotion strategies for the person in consultation and collaboration with the registered nurse.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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.

Required Skills and Knowledge

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.

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.

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.