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 Seek client cooperation and consent

1.3 Maintain client privacy and dignity

1.4 Utilise strategies to minimise cross-infection during assessment and implementation

1.5 Record data in line with organisation protocols, guidelines and procedures

1.6 Observe orders relating to non-disturbance of dressings

2. Assess the impact of a wound on a client and/or their family

2.1 Assist in performing a holistic client assessment

2.2 Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound

2.3 Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living

2.4 Take into account the common problems and complications of wounds when assessing a wound

2.5 Correctly use health terminology associated with wound care

2.6 Discuss the modes of transmission of infection and the development of infection with the client, family or significant other

3. Contribute to planning appropriate care for the client with a wound

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

3.2 Use contemporary assessment tools accurately

3.3 Access a database of wound care representatives to assist in wound care decision making

3.4 Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies

3.5 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

3.6 Demonstrate an understanding of the role of the members of the wound care health team in planning wound care

3.7 Discuss preventative wound care strategies with the client and/or family

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

3.9 Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required

4. Undertake clinical nursing care to implement wound care strategies

4.1 Apply an understanding of contemporary wound management strategies

4.2 Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse

4.3 Maintain client privacy and dignity throughout all aspects of the procedure

4.4 Implement wound care strategies taking into account legislation and organisation policies and procedures

4.5 Practise standard precautions in wound management to minimise the risk of infection to the client

4.6 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

4.7 Follow aseptic technique for clean surgical wound and use clean techniques where appropriate

4.8 Remove sutures, clips and drains as directed by a registered nurse

4.9 Collect specimens required for microbiology/ cytology as per organisation protocol

4.10 Dispose of all articles appropriately following the procedure, disposing of hazardous waste appropriately in line with organisation policies and procedures

4.11 Complete documentation and make the client comfortable

5. Assist in evaluating the outcomes of nursing actions

5.1 Monitor the client's response and progress towards planned wound management goals

5.2 Ensure client is involved in the evaluation process

5.3 Assist in assessing the effectiveness of wound management strategies

5.4 Assist in assessing the effectiveness of wound products

5.5 Modify wound management strategies, procedures and goals for the individual client in consultation/ collaboration with registered nurse

5.6 Work within a cost effective framework

5.7 Evaluate, document and communicate outcomes to the appropriate members of the health care team

5.8 Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology

5.9 Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse

6. Apply contemporary wound management strategies to complex or challenging wounds

6.1 Apply an understanding of the complexity of wounds encountered in the clinical environment and pathological processes of wound healing for complex or challenging wounds

6.2 Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team

6.3 Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse

6.4 Implement appropriate contemporary wound management strategies to manage complex or challenging wounds

6.5 Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse

6.6 Participate in a collaborative approach to wound management with members of the health care team

6.7 Identify the common problems and complications of complex and challenging wounds