Decision Making in Wound Management

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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)

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This is me!
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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

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What influences our decision making in wound care?

• Our personal level of knowledge/
  understanding/confidence/experience
• Whats 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

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Treatment plans are they useful?

• Treatment Plan A
• Problem
• Wound on L leg
• Treatment Objectives
• To heal
• Treatment Plan
• Hydrogel
• Absorbent Pad
• Stockinette
• Evaluation
• Static

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Treatment Plan B

• Problem
• 8 week history of wound above L ankle - 4cm x
  5cm tenacious slough
• with moderate exudate levels - bilateral leg
  oedema with dry skin plaques.
• Treatment Objectives
• Ascertain suitability for compression therapy.
• Remove slough to reveal wound bed
• Rehydrate dry skin areas and protect wound
  margins from further breakdown
• Manage exudate levels.
• Treatment Plan
• Vascular assessment with doppler test within 7
  days (repeated 3 monthly)
• Re-measure/photograph next visit and thereafter
  every 4 weeks
• Re-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 margins
• Cover with 10 x 10cm Eclypse pad held with
  actifast blue line toe to knee
• Compression system (K-Two)
• Evaluation
• Vascular Assessment confirms suitability for full
  compression therapy.

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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

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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.

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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

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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 users needs and medical status?
T Timed This means clearly stating when the objective should be achieved.
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Lets decide what to do with this
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Clinical Decision Making Process When Selecting
Woundcare Treatment

• Holistic Assessment to optimise treatment for
  co-morbidities and to accommodate patients
  personal assessed needs
• Wound Assessment
• Define and prioritise treatment objectives
• Ensure patients 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

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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

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How about this?

• Pressure/friction relief
• Pain relief
• Debride?
• Protect surrounding skin
• Manage exudate
• Risk Assessment esp. mobility issues

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Where shall we start?
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And this?

• Malignancy palliative
• Patients preferences
• Dignity issues
• Body image
• Malodour
• Exudate management
• End of life planning

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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

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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

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Finally.

• Thanks for listening and remember.. effective
  decision making can be empowering..............
• I would like to share with you a decision I made
  recently

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Some decisions are difficult to make but can be
life enhancing!