Unit of competency Outline

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Undertake basic wound care

Undertake basic wound care

Unit of competency
National Code
HLTEN406B
State Code
D8201
TGA Status
Replaced
DTWD Status
Deleted
Current Release Number
1.00
Current Release Date
25/03/2011
View on TGA
State Implementation and Classification
Approved Date
03/08/2011
Original Release Date
25/03/2011
Nominal Hours
30
Field of Education
060301 - General Nursing
Description
DescriptorThis unit involves the principles of infection prevention, in relation to wound care processes in a variety of health care contextsThis will include wound assessments and contemporary wound care working with the wound management health care team
General notes
N/A
Elements and 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
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
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
Replaces
State Code National Code Title Type
C9207 HLTEN406A Undertake basic wound care Unit of competency
No information