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Decision Making in Wound Management& the
Use of SMART Objective Setting in Treatment Planning to Improve Patient
Outcomes
Francine Nutt
Community Practice Teacher
(Shropshire England)
This is me!
Session content What factors influence our clinical decision
making? Treatment planning – how well do we do it? SMART objective setting in treatment
planning How can we ensure a consistent approach to
clinical treatment for our patients? Wound management decisions
What influences our decision making in wound care?
Our personal level of knowledge/ understanding/confidence/experience
What’s available within the care environment Access to wound management information (i.e.
Wound formularies? Product info leaflets?) Custom/Practice/Culture of the organisation Time available A clear treatment plan
Treatment plans – are they useful?Treatment Plan A
ProblemWound on L leg
Treatment ObjectivesTo heal
Treatment PlanHydrogelAbsorbent Pad Stockinette
EvaluationStatic
Treatment Plan BProblem8 week history of wound above L ankle - 4cm x 5cm tenacious sloughwith moderate exudate levels - bilateral leg oedema with dry skin plaques.Treatment ObjectivesAscertain suitability for compression therapy. Remove slough to reveal wound bedRehydrate dry skin areas and protect wound margins from further breakdownManage exudate levels. Treatment PlanVascular assessment with doppler test within 7 days (repeated 3 monthly)Re-measure/photograph next visit and thereafter every 4 weeksRe-dress twice weekly Wash legs using dermol soap substitute. Remove loose skin plaques. Cavilon film to proximal skin. Cetraben emollient knee to toe (3 pumps per leg) Actiform cool to sloughy wound bed both backing films removed –trimmed to provide 1cm overlap to
wound marginsCover with 10 x 10cm Eclypse pad held with actifast blue line toe to kneeCompression system – (K-Two)EvaluationVascular Assessment confirms suitability for full compression therapy. (Commenced K-Two)
How can we ensure a consistent approach? Thorough Assessment Documentation Clear treatment objectives which are SMART
(specific, measurable, achievable, relevant, timed) Patient in full agreement with treatment plan Professional respect for other team members
decisions Timely evaluation of treatment provided, to ensure
you are on track to achieve set treatment goals
KEY ELEMENTS OF AN OBJECTIVE
An objective: Is a specific and measurable description of the required treatment
Describes the intended result – the ”how much or what by when”
Is jointly agreed and prioritised between the service user and the nurse.
Should be set at the beginning of the care episode.
Should be reviewed regularly to ensure relevance to care needs
Provides a framework of measurable performance standards for care interventions within an agreed timescale.
BENEFITS OF OBJECTIVE SETTING
It provides clear direction for all nursing team members and the patient
It allows progress to be monitored and measured by the team. It helps build good relationships between the patient & the
nursing team and improves overall communication Helps to focus on a specific task Helps to prioritise care interventions Promotes regular and meaningful evaluation of care
interventions Enables success to be measured
SMART OBJECTIVESAll Objectives should be able to meet these key criteria
S Specific Ensure there is no ambiguity in the objective – it has a specific outcome to be accomplished. The outcome is
stated in a clearly defined manner.
M Measurable Is there a form of measurement in the objective? If it cannot be measured it will be difficult to assess/evaluate.
A Achievable Is it actually possible to achieve the objective within the time frame set, are the necessary resources available?
R Relevant Does the objective meet the service user’s needs and medical status?
T Timed This means clearly stating when the objective should be achieved.
Let’s decide what to do with this…
Clinical Decision Making Process When Selecting Woundcare Treatment Holistic Assessment to optimise treatment for co-
morbidities and to accommodate patient’s personal assessed needs
Wound Assessment Define and prioritise treatment objectives Ensure patient’s preferences are fully considered Identify performance criteria required from
dressing/products and select the most appropriate that meet all identified requirements
Timely Reviews as treatment objectives will invariably alter as wound progresses/ deteriorates
What are our priorities here?•Identify and maximise treatment for any co-morbidities, think how these may affect treatment options.
•Utilise a systematic wound assessment process (i.e. TIME)
•What are the treatment priorities and what is the patients perspective on these
•Consideration of what wound management options best meet the identified criteria to achieve treatment objectives
•Patient information re course of action
•Setting review date
How about this? Pressure/friction relief Pain relief Debride? Protect surrounding
skin Manage exudate Risk Assessment esp.
mobility issues
Where shall we start?
And this? Malignancy –
palliative Patient’s preferences Dignity issues Body image Malodour Exudate management End of life planning
Justifying our decisions How comfortable are we in detailing the
rationale for our treatment decisions? How do we feel when colleagues question our
decisions? Do we actively strive to improve our
knowledge of how wound care products work and how they can interact with each other
Decision making is a complex skill Be your own critic…. question yourself Take time to reflect on decisions you have
made… could the outcome have been different - better/worse
Embrace a student…… There is never only one course of
action/intervention A ‘good’ decision can only be reached if all
the component issues are actively considered
Finally…….
Thanks for listening and remember….. effective decision making can be empowering..............
I would like to share with you a decision I made recently
Some decisions are difficult to make but can be life enhancing!