hltenn006 apply principles of wound management in the ...€¦ · hltenn006 apply principles of...

HLT54115 Diploma of Nursing HLTENN006 – Version 4 October 2017

1

Student Assessment

HLTENN006 Apply principles of wound management in the clinical

environment

HLT54115 Diploma of Nursing

Record of Assessment Outcome

Student Name: Student ID:

Summary of evidence gathering techniques used for this assessment:

O Questioning O Scenario O Skill Assessment O Professional Practice Experience

The evidence presented is:

O Valid O Sufficient O Authentic O Current

Unit result: Competent O Not Competent O

The student has been provided with feedback and informed of the assessment result and the reason for the

decision.

Assessor Name: Date

Assessed:

Assessor Signature:

SCEI Contact [email protected]

Student declaration on feedback:

I have been provided with feedback on the evidence I have provided. I have been informed of the assessment

result and the reason for the decision.

Student Name: Date:

Student Signature:

Student Assessment


2

Student Assessment

Reasonable Adjustment

Was reasonable adjustment applied to any of the assessment tasks? (please tick) Yes O No O

If yes, tick which assessment task(s) it was applied to.

O Questioning O Scenario O Skill Assessment O Professional Practice Experience

Provide a description of the adjustment applied and why it was applied.

Name of Assessor:

Assessor Signature:

Name of Student:

Student Signature:

Student Declaration

Plagiarism constitutes extremely serious academic misconduct and severe penalties are associated with it. By signing below, you are declaring that the attached work is entirely your own (or where submitted to meet the requirements of an

approved group assessment, is the work of the group).

I certify that

I have read and understood the Southern Cross Education Institute’s PP77 Assessment and

submission policy and procedures.

This assessment is all my own work, and no part of this assessment has been copied from

another person.

I have not allowed my work to be copied by another person.

I have a copy of this work and will be able to reproduce within 24 hours if requested.

I give my consent for Southern Cross Education Institute to examine my work electronically by

relevant plagiarism software programs.

Student Signature: .......................................................... Date: ......../........../................


3

Student Assessment

ASSESSMENT OUTCOME SUMMARY AND FEEDBACK

Assessment Task 1 – Questioning

Submission No. Result Date Assessed Assessor Name Assessor Signature

O First submission O S O NS

O Re-submission 1 O S O NS


S = Satisfactory NS = Not Satisfactory

Feedback to the Student:

Assessment Task 2 – Scenario








4

Student Assessment

Assessment Task 3 – Skill Assessment







Assessment Task 4 - Professional Practice Experience


Name of assessor: Assessor signature:

PPE Type Date PPE

completed



5

Student Assessment

STUDENTS RESOURCES

Prescribed Resources (textbooks, DVDs, Journals, Publications)

Perry, A.G. Potter, A.P. & Ostendorf, R. W. (2016). Nursing Interventions & Clinical Skills. (6th Ed.). St. Louis: Elsevier

Crisp, J. Douglas, C. Rebeiro, G. Waters, D. (2017) Potter & Perry's Fundamentals of Nursing - Australian Version, (5th Edition) Elsevier, ISBN: 978-0-323-32740-4

Koutoukidis, G. Stainton, K. Hughson, J(2017) Tabbner's Nursing Care, (7th Edition) Elsvier, ISBN:

Scott, K. (2015). Long-Term Caring: Residential, Home and Community Aged Care. (3rd Ed.). Australia: Elsevier, ACN 001 002 357

Sheehay, S. B. (2013). Sheehay's MAnual of Emergency Care. (7th Ed.). St. Louis: Elsevier, ISBN 978-0-323-

07827-6

Online Resources

Nursing and Midwifery Board of Australia. Standards for Practice: Enrolled nurses.

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Enrolled-nurse-standards-for-practice.aspx

Nursing Care Plans (http://www.youtube.com/watch?v=h4I7yjuLMZo Nursing and Midwifery Board of Australia. Codes and Guidelines

Decision-making framework (NMBA 2013),

Nursing practice decisions summary guide (NMBA 2010),

Nursing practice decision flowchart (NMBA 2013),

Code of professional conduct for nurses in Australia (NMBA 2008),

Code of ethics for nurses in Australia (NMBA 2008), and

Professional boundaries for nurses in Australia (NMBA 2010). Victorian Government: Best care for older people everywhere

(http://www.health.vic.gov.au/older/toolkit/03Assessment/

Journal Articles/Recommended Websites/APA references

Moreira, M. E., & Markovchick, V. J. (2007). wound management. Emergency Medicine Clinical Of North America, 25(3), 873-899. Retrieved from https://www.clinicalkey.com.au/nursing/#!/content/journal/1-s2.0-

S073386270700065X

Recommended websites: Australian Wound Management Association – www.awma.com.au

Worldwide Wounds – www.worldwidewounds.com

European Wound Management Association – www.ewma.org

Wound Ostomy and Continence Nurses Society – www.wocn.org

Dressings – www.dressings.org

APA Referencing Guide

The University of Adelaide. (2012). APA Referencing Guide. https://www.adelaide.edu.au/writingcentre/docs/apa-style-guide.pdf

Flinders University (2017) APA Refrencing Guide

http://www.flinders.edu.au/slc_files/Documents/Blue%20Guides/APA%20Referencing.pdf

The University of Sydney. (2012). Your Guide to APA 6th Style Referencing http://sydney.edu.au/library/subjects/downloads/citation/APA%20Complete_2012.pdf

Clinical Key

http://www.youtube.com/watch?v=h4I7yjuLMZo

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx



http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx



http://www.health.vic.gov.au/older/toolkit/03Assessment/

http://www.awma.com.au/

http://www.worldwidewounds.com/

http://www.ewma.org/

http://www.wocn.org/

http://www.dressings.org/

http://sydney.edu.au/library/subjects/downloads/citation/APA%20Complete_2012.pdf


6

Student Assessment

Link to access Clinical Key for Nursing Elsevier (eBooks for Nursing)

https://www.clinicalkey.com.au/

Please note that you will need access to a computer with internet and a word processing software such

as Microsoft Word in order to complete this assessment.

https://www.clinicalkey.com.au/


7

Student Assessment

STUDENT INSTRUCTIONS AND SUMMERY OF ASSESSMENTS

This unit describes the skills and knowledge required to apply contemporary wound management

principles to the care of various types of wounds. It involves working with the interdisciplinary health

care team to contribute to assessment, treatment and ongoing management of a person’s wounds.

This unit applies to enrolled nursing work carried out in consultation and collaboration with registered

nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia

regulatory authority legislative requirements.

To achieve competence, you must:

Complete all theoretical assessment task within the designated timeframe

Achieve satisfactory mark in all practical skills assessment

Successfully complete Professional Practice Experience (PPE)

It is expected of you to spend additional hours outside the class allocated hours without supervision to

complete the theoretical assessment tasks.

If you do not understand any part of the unit or the assessments, please speak with your

trainer/assessor. It is our expectation that you fully understand all the aspects of this assessment

that you will be undertaking.

Refer to the table below for the summary of assessment tasks for this unit:

Assessment

Task Number

Assessment Type Notes

1 Questioning To be completed by the due date provided by

the trainer/assessor

2 Scenario

To be completed in the class and observed by

the trainer/assessor

3 Skills assessment To be conducted in the SCEI nursing skills

laboratory under the direct supervision of the

trainer/assessor

4 Professional Practice

Experience & Reflective

Journal

Completed in a SCEI approved Health Service.

All the units of competency must be deemed competent to complete the qualification and obtain a

certificate. The assessment requirement for this unit are presented clearly in the Unit of Competency

located at http://training.gov.au/Training/Details/HLTENN006

http://training.gov.au/Training/Details/HLTENN006


8

Student Assessment

Reasonable Adjustment

For information on reasonable adjustment please refer to the Student handbook located at:

http://scei.edu.au/wp-content/uploads/2017/08/2017_Student-Handbook_V4.pdf

Record of Assessment Outcome

After all of the assessment evidence has been gathered from the assessment tasks for this unit/cluster of

units of competency the Record of Assessment stating your result will be completed.

HLTENN004 - SIMULATED LABORATORY WORK

Please note : The following activities are to be demonstrated by the trainer

and performed by the student in the simulated laboratory, during the course

of unit delivery.

Total allocated lab

time for this unit:

12 Hours

ACTIVITIES

Aseptic technique

Dry dressing

Wound irrigation, wound swabs

Packing of wound

Suture, clip and staple removal

Drain removal and shortening

Wound Assessment

http://scei.edu.au/wp-content/uploads/2017/08/2017_Student-Handbook_V4.pdf


9

Student Assessment

ASSESSMENT CONDITIONS

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:

o wound care manikins

o wound care products

o dressing packs

o standard precautions and personal protective equipment (PPE)

o 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.


10

Student Assessment

ASSESSMENT TASK 1 – QUESTIONING

Instructions to the Student

Task 1 –

Questioning

You are required to answer all questions in Assessment Task 1 –

Questioning

Responses to the questions can be either typed or handwritten

Written responses must be legible and in pen NOT pencil

Use of correct grammar and spelling is required to demonstrate foundation

skills, so please ensure to proof read your answers prior to submission

Use of APA referencing must be used where original sources have been

used. Do not copy and paste text from any of the online sources. SCEI has

a strict plagiarism policy and students who are found guilty of plagiarism,

will be penalised. Please refer to APA referencing guide

http://www.flinders.edu.au/slc_files/Documents/Blue%20Guides/APA%20Ref

erencing.pdf

Write your name, student ID, the assessment task and the name of the unit

of competency on each piece of paper you attach to this assessment

document

You are required to submit this assessment to your trainer/assessor by the

due date

Word Limit is less than 100 words for each answer.

Due Date The trainer/assessor will inform you of the due date.




11

Student Assessment

1. How would you ensure that your client’s privacy and dignity are maintained during holistic

assessment and wound management activities?

2. Label the following diagram of the skin layers.

3. List the stages of wound healing. For each stage describe the critical changes that occur at cell,

biochemical and tissue level, using appropriate medical terminology.

4. Outline 5 key factors that may affect wound healing, including psychological impact of a wound on

the person’s activities of daily living. What is the ideal environment for wound healing?

5. The clinical appearance of a wound is very important in the assessment of healing progress and also

to identify the stage of healing that a wound is at.

Define the following characteristics of wound tissue:

a. Necrotic

b. Sloughy

c. Granulating

d. Epithelizing

6. Wound infection is a serious complication which may delay or reverse healing leading to greater

tissue damage or systemic illness. State the 5 common clinical manifestations of wound infection.

How can you prevent, minimise cross-infection, consider client/family education.

7. Wound exudate can be described as being serous, haemoserous, sanguinous or purulent.

State the characteristics of each:

a. Serous

b. Haemoserous

c. Sanguinous

d. Purulent

8. List 3 other characteristics of wound exudate that you would include in your assessment of a

person’s wound.

9. List 3 criteria to consider when undertaking assessment of the skin surrounding a wound.

10. Pain related to a wound needs to be assessed and treated promptly and appropriately. List 5

factors that may contribute to pain related to a wound.


12

Student Assessment

11. State 4 ways wounds can have a psychosocial impact on an individual’s ADL’s.

12. State 10 factors you would consider in developing a wound management plan and provide rationale

for each factor stated.

13. List the members of the health care team who may be involved in wound management in the

hospital setting.

14. As part of the management plan, what 4 key instructions should be included when educating the

client/family in regard to wound-damage/infection prevention strategies?

15. State 5 intrinsic client factors/conditions that may increase the risk of wound development and/or

delay wound healing.

16. For the following dressing categories, identify the key indication for use and provide rationale for

your answer. Also state one example (brand) of the product.

a. Semipermeable film

b. Foam

c. Hydrocolloid

d. Hydrogel

e. Alginates

f. Multilayer absorbent pad

g. Odour absorbing

h. Pressure reducing

i. Silicone

j. Ionic Silver

k. Haemostatic agent

l. Manuka honey

m. Negative pressure therapy devices

17. It is the nurse’s responsibility to observe and document healing progress. With regard to a surgical

wound with staples insitu, what 5 specific observations would you make?

18. State 5 criteria you would use in evaluating the effectiveness of wound management strategies.

19. State 5 criteria you would use in assessing the effectiveness of a dressing product for a particular

wound taking into consideration cost effective framework.

20. Ulcers occurring on the lower leg may be complex in their aetiology and are a sign of underlying

disease, trauma or allergic response.

Define the following types of ulcers that typically occur on the lower leg indicate what type of

treatment would be used on each type of ulcer, for example compression therapy:


13

Student Assessment

a. Arterial ulcers

b. Venous ulcers

c. Mixed Arterial/Venous

d. Neuropathic ulcerating wound

e. What is Doppler Ultrasound used for

21. Pressure Injury is one of the most common hospital acquired injuries. In order to accurately assess

the depth of a Pressure Injury we utilise a 5 stage assessment model. State the key characteristics

for each of the five stages.

22. State the 3 principle causes of Pressure Injury and include a brief description of how each cause

contributes to the development of a Pressure Injury.

23. State 3 intrinsic factors that may lead to a person sustaining a Pressure Injury

24. Skin Tears are the most commonly acquired traumatic wound by people living in residential aged

care.

a) State the name of the classification system used to identify the severity of a skin tear

b) List the 3 categories of Skin Tear and state the assessment criteria for each

c) State the 3 most appropriate dressing categories to be used for dressing skin tears

25. Your patient had skin graft to his lower left leg which has taken well. The order is daily dressing

and weekly wound measurement. His donor site is on right thigh, covered with dry dressing which

is now oozing through. The order is not to disturb the dressing for another 5 days. What are you

going to do? Which members of the interdisciplinary team are you going to consult about this

issue?

26. Find current nursing article from the Clinical Key On line library on wound management which

discusses best practice and latest research and attach to the assessment. Write a short summary

and why you chose the article.

27. Under what circumstances you will see wound drain and why?

28. what is the importance of wound cleaning. Explain the difference between primary and secondary

dressings.


14

Student Assessment

ASSESSMENT TASK 2– SCENARIO


Task 4 –

Scenario

Responses to the questions can be typed or submitted handwritten

Assessment requirements may be either typed or handwritten

If hand written, the writing must be legible and in pen NOT pencil

Written responses must be legible and in pen NOT pencil

Use of correct grammar and spelling is required to demonstrate foundation skills, so

please ensure to proof read your answers prior to submission

Use of APA referencing must be used where original sources have been used. Do not

copy and paste text from any of the online sources. SCEI has a strict plagiarism policy

and students who are found guilty of plagiarism, will be penalised. Please refer to APA

referencing guide


Write your name, student ID, the assessment task and the name of the unit of

competency on each piece of paper you attach to this assessment document

You are required to submit to your trainer/assessor by the due date all aspects of this

assessment:

o Power point presentation

o A3 poster

o Evidence of research

Due Date The trainer/assessor will inform you of the due date.

Scenario One

Mary Gordon is an elderly lady who was admitted to a medical ward for treatment of a gastrointestinal

infection. Mary is on bed rest and requires full assistance with all activities of daily living. She has

frequent uncontrolled diarrhoea and her nurse has been providing excellent care to maintain her

cleanliness, comfort and dignity. Following one episode of providing perineal care for Mary and changing


15

Student Assessment

the bed linen, the nurse is called immediately to another client to attend to a dressing that has started to

fall off a person’s large abdominal visceral wound. The nurse’s hands were not washed before attending

to the dressing. That client subsequently developed an infection in her wound – the pathogen was

identified as Escherichia Coli.

1. Clearly explain what is visceral wound, type of dressings suitable to use and the origin of Escherchia

Coli pathogen. Identify each of the following the chain of infection criteria in relation to scenario 1;

for each criteria identified explain how you arrived at your answer:

o Infectious agent

o Reservoir

o Portal of exit

o Mode of transmission

o Susceptible host and immunity

2. State 3 ways this cross infection episode could have been avoided. Provide an explanation for each

of the ways you identify.

3. State the principle clinical manifestations associated with wound infection and explain the

fundamental physiological reasons for each of the symptoms and how it affects the person’s

activities of daily living.

4. Define National Safety and Quality Health Services Standards as related to this scenario.

5. What would be the appropriate dressing to use on large visceral wound? The wound is dehisced

surgical incision healing by secondary mode of healing. It is oozing large amounts heamerous.

Scenario Two

John Henderson is a 45 year old man who is in patient in the Burns ward. He sustained 3 degree burns

to his abdomen and legs when he tried to control accidental fire in his shed. He undergone grafting

surgery to cover area on his abdomen. It is day 5 since Mr. Henderson’s surgery. Last night he was

febrile 37.9 and when his dressing was changed it was noted that the wound was red, warm to touch

and swollen. A small amount of purulent discharge was also observed. Mr. Henderson’s treating doctor

has requested a wound swab for micro culture and sensitivity (MC&S).

1. Describe staging of burns. What treatment will be given to Mrs Henderson during his stay in

hospital, include choice of dressing to manage grafts and donor sites and pain management care,

outline the plan.

2. Describe psychological and physical impact on Mr Henderson


16

Student Assessment

3. Include members of multidisciplinary team who will be part of his treatment and discharge planning,

including community support post discharge.

4. The registered nurse you are working with has delegated the task of collecting the specimen to

you. What equipment will you need to gather in preparation for collecting the specimen? Why the

doctor did ordered the swab?

5. Describe how you will perform the specimen collection: ensure that all aspects of patient care are

addressed and the specimen collection method you employ is based on best available evidence, is it

advisable to clean the wound before collecting the specimen or after? Give rationale.

Gain patient’s consent-inform them what you are going to do. Wash hands with soap and water. Put

on gloves. Remove the old dressing and put it into the garbage bag. Observe wound and take note

of wound characteristics and look for abnormalities. Change gloves. Clean trolley with solution and

dry it thoroughly. Open dressing pack using aseptic technique. Set up the dressing pack on the

trolley. Infection will be the exudate, so DO NOT clean the wound! Prepare the swab and take the

sample depending on the method required

Swab for exudate

Z technique

Lavine technique

Swabbing in a zigzag pattern and rotating

Swab area of viable tissue where signs of infection are present. Put the swab into a transport

medium. Take off gloves and clean hands with soap and water. Label containers with patient’s

name, date specimen collected and time and type and unit number. Place into pathology bag with

the slip. Dispose of the dressing pack appropriately, cleanse trolley with solution and return to the

appropriate storage area. Send swab to pathology ASAP. Document into the patient’s notes.

(Dorevitch Pathology, 2011; Gibb, 2013: Grampians Region Health Collaborative, 2011).

6. What is the potential cause of suspected infection, describe the importance of infection prevention

in patients with burns

7. Define National Safety and Quality Health Services Standards as related to this scenario

8. State the documentation you would include in Mr. Henderson’s progress notes.

The time and date that you took the specimen (MC&S), the site and location of the wound where

the swab was done, the type of specimen or swab that was done, the time that it was sent to

pathology, the time it was placed to be picked up. That the dressing was redressed/changed as per

the wound chart, if there were any changes or deteriorations list them- all details in the notes and

state that you notified a more senior nurse and also the patient’s Doctor.

(Dorevitch Pathology, 2011; Gibb, 2013: Grampians Region Health Collaborative, 2011).


17

Student Assessment

Scenario Three

Cathy Cartwheel is 77 years old lady, she is living independently with her husband. She has a past history

of Hypertension Type 2 Diabetes, OA in her right knee. She developed an ulcer which has been

diagnosed as Diabetic ulcer. In the past she suffered from venous ulcer due to Hypertension and

impaired circulation.

1. Define pathophysiology of Diabetic, Venous and arterial ulcer, include signs and symptoms and

how would you differentiate those.

2. What tools are used to diagnose ulcers?

3. Describe treatment for Diabetic, Venous and Arterial ulcers. Compare contemporary treatment

strategies with available treatment in the past. Outline historical development in wound care

practices.

4. You are her community nurse, create a care plan with time frames for reviews using primary

health care principles and holistic

Approach to plan her wound care, consider dietary intake, diabetes management. What health

care professionals you will involve to help Cathy to manage her wound and wound healing

effectively. Include need for pain relieve for Cathy.

5. Create an educational lifestyle program for her and her family, including infection prevention and

understanding modes of transmissions.

6. During the wound assessment you have noticed that there is significant amount of slough covering

area from 1200 o’clock to 6 o’clock of the wound bed. Define the terminology of slough and why

would you need to debride the area. How is debridement done and what is your scope of practice

in this instance?


18

Student Assessment

ASSESSMENT TASK 3 – SKILLS ASSESSMENT


Task 3- skills

This assessment must be deemed satisfactory by the trainer/assessor prior

to commencing professional practice

The assessment is conducted in the SCEI simulated nursing laboratory

This assessment task requires the student to be directly observed by the

trainer/assessor in performing the tasks described below in a safe and

competent manner

The Student’s performance should mimic the relations and communications

between the patient before, during and post the wound management

procedure.

The trainer/assessor will provide the student with a scenario for each

assessment task and the student is required to perform the procedure

accordingly.

The student will be required to achieve successful performance in

demonstrating safe hand hygiene practices

Due Date

The trainer/assessor will inform you of the due date .

In a simulated setting you will be assessed on the demonstration of each of the nursing procedures listed

below on an adult, child and infant manikin. You must achieve a satisfactory result on each of the

following nursing procedures.

o Aseptic technique

o Dry dressing

o Wound irrigation, wound swabs

o Packing of wound

o Suture, clip and staple removal

o Drain removal and shortening

o Wound Assessment


19

Student Assessment

HLTENN006 - Skills Demonstration Checklist

1. Dry Dressing using Aseptic Technique

Student’s

Name

Student ID

Procedural Steps Satisfactory Not

Satisfactory

1. Identifies indication O O

2. Performs hand hygiene O O

3. Gathers equipment:

Dressing pack

Gloves

Sterile solution (usually NSI)

Waste disposal bag

Dressing as ordered

tape

O O

4. Confirms the sterility of the packages O O

5. Demonstrates problem-solving abilities; e.g. positions patient

comfortably O O

6. Evidence of effective communication with patient: explains

procedure to patient O O

7. Prepares room O O

8. Dons gloves prn O O

9. Removes soiled dressing O O

10. Assesses the wound O O

11. Washes hands/ Performs hand hygiene O O

12. Opens the package O O

13. Adds necessary sterile supplies O O

14. Performs hand hygiene again O O

15. Uses sterile forceps to handle sterile supplies O O

16. Performs required procedure

Maintains principles of asepsis throughout procedure

Cleanses wound, assesses wound

Applies dry dressing

Secures dressing

O O

17. Cleans, replaces and disposes of equipment appropriately O O

18. Documents and reports relevant information O O

19. Demonstrates ability to link theory to practice O O

Assessor’s general comments/observations:

Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not Satisfactory)

Student’s

name

Student’s

signature


20

Student Assessment


2. Packing a Wound

Student’s

Name

Student ID


Satisfactory


2. Demonstrates problem-solving abilities; e.g. administers

analgesia, provides privacy, positions patient appropriately O O

3. Evidence of effective communication with the patient; e.g. gives

patient a clear explanation of procedure O O

4. Gathers equipment

Clean gloves

Dressing tray

Sterile gloves

NS or other cleansing solution

Sterile gauze or irrigation set

Forceps

Sterile scissors

Packing material as ordered

Tape

O O

5. Dons appropriate protective apparel O O



8. Establishes the sterile field , cleanses wound O O

9. Assesses wound and surrounding tissue O O

10. Packs wound O O

11. Applies dry dressing and secures O O


13. Documents relevant information O O



Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not

Satisfactory)

Student’s

name

Student’s

signature


21

Student Assessment


3. Wound Assessment

Student’s

Name

Student ID


Satisfactory


2. Demonstrates problem-solving framework; e.g. administers analgesia,

provides privacy, positions patient appropriately O O






7. Assesses the wound and surrounding tissue O O

8. Measures the wound diameters with sterile measuring tape O O

9. Measures the wound’s depth, able to identify undermining and tracing

issue using a probe O O

10. Take a photographic evidence as per organisational policy O O

11. Traces the wound if applicable ( Cellulitis, rash)

12. Cleans and covers the wound with appropriate dressing O O


14. Documents relevant information on wound assessment chart using

correct medical terminology O O



Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not Satisfactory)

Student’s

name

Student’s signature



22

Student Assessment

4. Wound swab/wound irrigation

Student’s

Name

Student ID


Satisfactory


2. Demonstrates problem-solving framework ; e.g. administers analgesia,

provides privacy, positions patient appropriately O O






7. Assesses the wound and surrounding tissue O O

8. States reason for taking swab form the wound O O

9. Gathers Equipment

Dressing/drape pack, small soft catheter if

required

Irrigating syringe

Sterile solution (saline 0.9%)

Waterproof bag

Wound ruler if required

Tape

Kidney dish, blue sheet

Gloves, apron, eye protection

Swab sticks

O O

10. Establishes and maintains sterile field O O

11. Irrigates and assesses wound O O

12. Covers the wound with appropriate dressing O O


14. If requested ensures wound culture is send to laboratory with request

form O O





Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not Satisfactory)

Student’s

name



23

Student Assessment


5. Drain Removal and Shortening

Student’s

Name

Student ID


Satisfactory


2. Demonstrates problem-solving framework ; e.g. administers

analgesia, provides privacy, positions patient appropriately O O





6. Gathers Equipment:

Clean and sterile gloves

Sterile scissors and stich removal

Sharps container

Dressing pack

Steri- strips

Blue sheet

O O

7. Prepares equipment and releases suction on the drain as per policy O O

8. Shortens/removes drain as ordered O O






Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not Satisfactory)

Student’s

name



24

Student Assessment


6. Suture clip and staples removal

Student’s

Name

Student ID


Satisfactory 1. Identifies indication O O 2. Demonstrates problem-solving framework

; e.g. administers analgesia, provides privacy, positions patient

appropriately O O

3. Evidence of effective communication with the patient; e.g. gives patient a clear explanation of procedure

O O

4. Dons appropriate protective apparel O O 5. Performs hand hygiene O O 6. Removes soiled dressing O O 7. Assesses the wound and surrounding tissue O O 8. States reason for taking swab form the wound O O 9. Gathers Equipment

Dressing pack

Sterile solution (saline 0.9%)

Kidney dish, blue sheet

Sharps container

Gloves

Required dressing

Sterile scissors ,stich remover/staples remover

O O

10. Establishes and maintains sterile field O O 11. Position the patient O O 12. Sets up dressing tray O O 13. Removes sutures/staples/clips O O

14. Cleans and dresses wound O O

15. Cleans, replaces and disposes of equipment appropriately O O 16. If requested ensures wound culture is send to laboratory with request form O O

17. Documents relevant information on wound assessment chart using correct medical terminology

O O



Assessor’s

name

Assessor’s

signature

Date Outcome

(Please circle)

S

(Satisfactory)

NS

(Not Satisfactory)

Student’s

name



25

Student Assessment

ASSESSMENT TASK 4

PROFESSIONAL PRACTICE EXPERIENCE


Task 5-PPE You are required to undertake professional practice experience

(PPE) at the completion of the theoretical component of semester

two

You must achieve a successful result in all the theoretical and

practical skills assessments for allocated units of competency prior to

commencing professional practice experience

All Prior to placement allocation and commencement you will be

required to undergo a final pre –placement assessment which will be

conducted by your trainer as well as the clinical lab assessor.

The SCEI work placement coordinator will arrange your professional

practice to ensure it is undertaken in a SCEI approved and supervised

health facility

You must complete all requirements of the PP RECORD booklet

This assessment is graded as satisfactory or unsatisfactory. An

unsatisfactory result will mean an overall unit of competency

outcome as not yet competent.

Due Date • The professional practice booklet including your reflective

journals must be submitted to the trainer/assessor within five days of

completion of the professional practice

Prior to attending work placement, you will be issued with a Professional Practice (PP) Record Book.

This book is to provide you and the Clinical Assessor with performance criteria for a standard of

competency that would be expected of an Enrolled Nurse at the completion of each Professional

Practice (Aged Care, Mental Health, Community, Sub-Acute Care and Acute Care). The performance


26

Student Assessment

criteria articulates to the expected knowledge, skills and attitudes required of an Enrolled Nurse and

aligns to the domains of practice in the Enrolled Nurse standards for practice.

This book will outline:

Professional Practice Objectives

The roles and responsibilities of the Student and the Clinical Assessor

Clinical Skills

Formative and Summative assessments.

It is critical that during the professional practice, you will consistently demonstrate achievement of the

required skills, knowledge and the ability to complete tasks as outlined in the elements and performance

criteria of this unit, manage tasks and contingencies in the context of your role within your scope of

practice. You must undertake nursing work in accordance with the Nursing and Midwifery Board of

Australia Professional Practice Standards, Codes and Guidelines during your placement.

This includes the ability to:

1. 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

o At least 1 must involve a simple wound dressing and

o At least 1 must involve a complex wound dressing.

For more details please refer to the extract from Professional Practice Experience Record

Book.

EXTRACT FROM PPE RECORD BOOK

Professional Practice Experience Checklist

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 your role within

your scope of practice. There must be evidence that the candidate

has:

Tick appropriate column as per

student’s assessment:

I= Independent Level,

S= Requires Supervision,

A= Requires Minimal Assistance,

U=Unsatisfactory.

(Satisfactory results are I, S and

A.)

I S A U

The student has performed wound care management, including

wound assessment, health education and evaluation of the

person’s wound care in the workplace on 3 simple wound

dressings, of which


27

Student Assessment

o At least 1 must involve a simple wound dressing

and

o At least 1 must involve a complex wound

dressing.

undertaken nursing work in accordance with Nursing and

Midwifery Board of Australia professional practice standards,

codes and guidelines

The student has considered primary health care principles and

holistic approaches when planning care for the person with a

wound.

The student has approached wound care experts to assist in

decision-making for wound care management.

The student has contributed to an individual wound management

plan for the person in consultation and collaboration with the

person, registered nurse and the interdisciplinary health care

team.

The student has participated with the interdisciplinary health care

team in making an assessment of the person with a complex or

challenging wound within an holistic framework.