HLT54115 Diploma of Nursing
HLTENN006 Apply principles of wound management in the clinical environment
Workplace Assessment Student Copy
Instructions to Students
Welcome to the written assessment. To successfully complete the assessment requirements, you need to follow the following instructions.
Read the study guide and the related resources.
Read this assessment to gain an understanding of what you need to do to complete the unit. Talk to your trainer or supervisor and ask for help if you need to.
Complete all questions in this assessment. Please write clearly in pen (not pencil). You may attach printed answers if you prefer. Do not remove any pages from this assessment.
Complete the cover sheet and attach to this assessment. We recommend you make and keep a copy of the entire Assessment.
Submit for assessment.
Assessment Tool 3 and Assessment Tool 4
Workplace Skills Assessment
Assessors make professional judgements about the competence of the students to meet the requirements of the unit of study. this requires assessors to gather evidence that is:
• valid- covers all the requirements of the unit of competency
• sufficient- enables a decision about competency over time and in different contexts
• current- competent performance is contemporary
• authentic- is the students own work.
Assessment considers Professional Standards including the Australian Nursing and Midwifery Council Enrolled nurse competency standards and the Standards for Practice Enrolled Nurses, Code of Conduct and Code of Ethics. More information can be found at http://www.nursingmidwiferyboard.gov.au/
Workplace skills assessment is an integral component of learning and training. embedded in the assessments are employability skills that are required by industry for this qualification. the employability skills described here are broad industry requirements that may vary depending on qualification packaging options.
• Listening to and understanding work instructions, directions and feedback
• Speaking clearly/directly to relay information
• Reading and interpreting workplace related documentation, such as safety requirements and work instructions
• Writing to address audience needs, such as work notes and reports
• Interpreting the needs of internal/ external clients from clear information
• Applying numeracy skills to workplace requirements involving measuring and counting
• Establishing and using networks
• Sharing information (eg. with other staff and clients)
• Negotiating responsively (eg. re own work role and/or conditions, possibly with clients)
• Persuading effectively (ie. within scope of own work role)
• Being appropriately assertive (eg. in relation to safe or ethical work practices and own work role)
• Empathising (eg. in relation to others)
• Working as an individual and a team member
• Working with diverse individuals and groups
• Applying knowledge of own role as part of a team
• Applying teamwork skills to a range of situations
• Identifying and utilising the strengths of other team members (and providing encouragements and support to colleagues)
• Giving feedback, coaching and mentoring
• Developing practical and creative solutions to workplace problems (ie. within scope of own role)
• Showing independence and initiative in identifying problems (ie. within scope of own role)
• Solving problems individually or in teams (ie. within scope of own role)
• Applying a range of strategies in problem solving
• Using numeracy skills to solve problems (eg. time management, simple calculations, shift handover)
• Testing assumptions and taking context into account (ie. with an awareness of assumptions made and work context)
• Listening to and resolving concerns in relation to workplace issues
• Resolving client concerns relative to workplace responsibilities (ie. if role has direct client contact)
Initiative and Enterprise
• Adapting to new situations (ie. within scope of own role)
• Being creative in response to workplace challenges (ie. within relevant guidelines and protocols)
• Identifying opportunities that might not be obvious to others (ie. within a team or supervised work context, including identification of skill gaps)
• Generating a range of options in response to workplace matters
• Translating ideas into action (ie. within own work role)
• Developing innovative solutions (ie. within a team or supervised work context and within established guidelines)
Planning and Organising
• Collecting, analysing and organising information (ie. within scope of own role)
• Using organisational systems for planning and organising (ie. if applicable to own role)
• Being appropriately resourceful (ie. within scope of own role)
• Taking initiative and making decisions within workplace role (ie. within authorised limits)
• Participating in continuous improvement and planning processes (ie. within scope of own role)
• Working within clear work goals and deliverables
• Determining or applying required resources (ie. within scope of own role)
• Allocating people and other resources to tasks and workplace requirements (ie. within scope of own role)
• Managing time and priorities (ie. in relation to tasks required for own role)
• Adapting resource allocations to cope with contingencies (ie. if relevant to own role)
• Being self-motivated (ie. in relation to requirements of own work role)
• Articulating own ideas and vision (ie. within a team or supervised work context)
• Balancing own ideas. values and vision with workplace values and requirements
• Monitoring and evaluating own performance (ie. within a team or supervised work context)
• Taking responsibility at the appropriate level
• Being open to learning new ideas and techniques
• Learning in a range of settings including informal learning
• Participating in ongoing learning
• Learning in order to accommodate change
• Learning new skills and techniques
• Taking responsibility for own learning (ie. within scope of own work role)
• Contributing to the learning of others (eg. by sharing information)
• Applying a range of learning approaches (ie. as provided)
• Participating in developing own learning plans (eg. as part of professional development)
? Using technology and related workplace equipment (ie. if within scope of own role)
? Using basic technology skills to organise data
? Adapting to new technology skill requirements (ie. within scope of own role)
? Applying WHS knowledge when using technology
? Applying technology as a management tool
The Workplace Assessment Task(s) include two sections
• Assessment Tool 3
• Third Party Report Assessment Tool 4
The Workplace Assessment Tasks are required to be completed by the workplace supervisor and/or assessor using the forms provided. It is the role of the assessor to clearly articulate the assessment process, contact the student and coordinate with the student and the workplace supervisor to plan this assessment.
An integrated or holistic approach to competency-based assessment has been adopted to include workplace skills assessment. The workplace supervisor and/or assessor is integral to the success of workplace training and assessment. The RTO is responsible for ensuring that the necessary training and assessment meets the required standard of the qualification. Workplace training supports students through a range of training that is formal and informal. The RTO is responsible for the final assessment of the required competencies of a qualification, which must be completed by a qualified assessor.
Assessment Tool 3
Workplace Skills Assessment
Workplace Supervisor Name:
Unit of Competency:
Name of Workplace:
Date of assessment:
Procedure: Observation of student in the workplace undertaking management of skin integrity and wound management, chronic wounds.
STAR The STAR method is a structured approach of assessment in which the student describes a previous experience that demonstrates a specific competency. The acronym STAR
• Situation- describe the situation
• Task- describe the strategy that was taken with the situation
• Action – demonstrate and highlight the skills and knowledge
• Result- student outcomes
This is a universally recognised communication technique designed to enable students to provide meaningful and complete answers.
Situation or Task: Enrolled/Division 2 nurses apply contemporary wound management principles to the care of clients with varying types of wounds. The knowledge and skills described in this competency unit are to be applied within jurisdictional nursing and midwifery regulatory authority legislative requirements
Enrolled/Division 2 nursing work is to be carried out in consultation/collaboration with registered nurses and under direct or indirect supervisory arrangements in line with jurisdictional regulatory requirements
Action: The Workplace Supervisor and/or Assessor is to observe the student performing the task and place a tick in the appropriate boxes on the Workplace Assessment Task checklist attached.
Upon completion of the Workplace Assessment Task Checklist, detail any additional comments to support your observations and then sign and date the checklist.
Outcome: Performance Evidence
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
• 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:
• 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
• 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.
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.
Assessment Tool 3
Discussion Questions- Assessor is to discuss each wound before student attends to the dressing.
Apply Principals of wound management in the clinical environment
CLINICAL SKILL Discussion: Applying contemporary wound management principals to the care of clients with varying types of wounds. Before attending to a wound dressing, students are to be deemed competent in the following questions. Students are to attend to 5 dressings while on clinical placement, and be deemed competent in each dressing.. The assessor is required to discuss each wound before the student attends to the dressing. The assessor is required to be present for the 5 wound dressings and provide the student with feedback Comment
1. How would you identify the need for a wound dressing
2. How would you identify the type of wound, using appropriate medical terminology
Planning – Expected Outcomes
1. What are the expected outcomes for the wound
2. What equipment do you require to attend to the dressing
1. What are the standard protocols for all nursing interventions?
2. Review a nursing care plan for a client who has a wound. Discuss the steps that you would undertake to complete the dressing change for this client.
1. How would you evaluate the wound after completing the dressing?
Assessor Signature and Date Student Signature and Date
Assessment Tool 3
Student Observation- Demonstrates the ability to effectively and safely complete a dressing. Students are required to perform a minimum of two dressings. Assessor is required to be a Registered Nurse (Div 1). Students are to required to document procedures using the organisations documentation provided, this may include wound pathways, dressing plans, nursing care plans and progress notes. It is a requirement that the assessor, Registered Nurse (Div 1), has assessed the documentation.
Dressing 1- Simple Dressing 2- Complex Dressing 3- Simple or Complex Removal of sutures or staples
Identify the need for a wound dressing
Planning –expected Outcomes
What are the expected outcomes for the wound
What equipment do you require to attend to the dressing
What are the standard protocols for all nursing interventions?
Student reviews the nursing care plan for a client who has a wound.
Introduces self and discusses procedure with the client. Discusses pain with the client
Observes the wound and remove the old dressing using infection control techniques
- Washes hands ?
- Dons gloves ?
- Removes dressing ?
- Disposes appropriately ?
Observes for any changes in wound and gathers equipment necessary
Washes hands and prepares sterile field, with Sodium Chloride and appropriate dressing
Uses sterile technique’ for opening all packages and dressings
Cleans the wound from the “inside out” using a non-touch technique
Applies the appropriate dressing to the wound
Assesses the comfort of the client
Disposes of equipment correctly
Documents procedure and changes on wound care assessment chart. Reports to RN
How would you evaluate the wound after completing the dressing?
Assessor Signature and Date Student Signature and Date
Assessor Signature and Date Student Signature and Date
Assessment Tool 3
As an enrolled nurse, you need to have gained an understanding of the underlying principles of wound care to enable you to communicate this knowledge to your clients while working as part of a multidisciplinary team.
1. What are the National Safety and Quality Health Service (NSQHS) Standards
2. Undertake an assessment of a client with a complex or challenging wound, gathering subjective and objective data.
3. Draw the complex or challenging wound that you have assessed, identifying the layers involved and detailing the pathological processes involved.
4. Create a plan of care for your client with a complex or challenging wound, using the data collected in your assessment, and in consultation with a registered nurse.
5. Review products to use on the complex or challenging wound, including rationale and cost of products together with a teaching plan for the client.
6. Evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation with the registered nurse
7. Outline the psychosocial impact on the client and the family
8. List the community and educational resources and professional organisations associated with wound management
9. Complete progress notes
Reference the source of all information and include a reference list
Assessment Tool 4
Supervisor Workplace Observation Statement
Instructions for Workplace Supervisor/Third Party
The collection of third party evidence provides assessors with authentic and valid evidence. The completion of this report will provide complementary evidence for the assessor to make the professional judgement about the achievement of competency.
Name of Supervisor/Third Party:
Qualifications (please attach)
Relationship to student:
Task Feedback Date Supervisor Initials
Demonstrate understanding of common ways disease is spread and infection is developed throughout wound assessment and care
Seek client cooperation and consent
Maintain client privacy and dignity throughout all aspects of the procedure
Utilise strategies to minimise cross-infection during assessment and implementation
Record data in line with organisation protocols, guidelines and procedures
Observe orders relating to non-disturbance of dressings
Assist in performing a holistic client assessment
Apply an understanding of the physiological and biochemical processes associated with normal wound healing when assessing a wound
Consider factors which impact on wound healing and the psychosocial impact of a wound on the client's activities of daily living
Take into account the common problems and complications of wounds when assessing a wound
Correctly use health terminology associated with wound care
Discuss the modes of transmission of infection and the development of infection with the client, family or significant other
Take into account primary health care principles and holistic approach when planning care
Use contemporary assessment tools accurately
Access a database of wound care representatives to assist in wound care decision making
Use an evidence-based problem solving approach to contribute to the analysis and planning of appropriate wound care management strategies
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
Demonstrate an understanding of the role of the members of the wound care health team in planning wound care
Discuss preventative wound care strategies with the client and/or family
Identify client comfort needs (eg. pain relief) before undertaking wound care
Consult with the registered nurse regarding analgesic administration within an optimal time frame of procedure if required
Apply an understanding of contemporary wound management strategies
Evaluate, document and communicate outcomes to the appropriate members of the health care team
Document progress of wound healing and wound care strategy outcomes using contemporary wound management terminology
Educate the client and/or family on wound management strategies in consultation/ collaboration with a registered nurse
Identify and plan health education and promotion strategies in consultation/collaboration with the registered nurse
Apply an understanding of the complexity of wounds encountered in the clinical environment and pathological processes of wound healing for complex or challenging wounds
Assist to assess the client with a complex or challenging wound within a holistic framework, in consultation/collaboration with the health care team
Create and review individualised plans of care for the client with a complex or challenging wound, in consultation/collaboration with the registered nurse
Implement appropriate contemporary wound management strategies to manage complex or challenging wounds
Assist to evaluate the effectiveness of the planned care for the client with complex or challenging wounds in consultation/collaboration with the registered nurse
Participate in a collaborative approach to wound management with members of the health care team
Identify the common problems and complications of complex and challenging wounds
Supervisor/Third Party Declaration
I declare that I have observed the student perform the workplace assessment/s in line with the criteria stated in the assessments. I confirm that I have not received any inducements to complete this report and have advised of any personal relationship with the student.