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
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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?
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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?
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Problem
Wound on L leg
Treatment Objectives
To heal
Treatment Plan
Hydrogel
Absorbent Pad
Stockinette
Evaluation
Static
Treatment Plan A
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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
How can we ensure a consistent
approach?
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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
KEY ELEMENTS OF AN
OBJECTIVE
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An objective:
Is a specific and measurable description of the required treatment
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Describes the intended result – the ”how much or what by when”
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Is jointly agreed and prioritised between the service user and the nurse.
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Should be set at the beginning of the care episode.
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Should be reviewed regularly to ensure relevance to care needs
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Provides a framework of measurable performance standards for care
interventions within an agreed timescale.
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BENEFITS OF OBJECTIVE
SETTING
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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 OBJECTIVES
All 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
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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
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?
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Pressure/friction
relief
Pain relief
Debride?
Protect surrounding
skin
Manage exudate
Risk Assessment
esp. mobility issues
Where shall we start?
And this?
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Malignancy –
palliative
Patient’s
preferences
Dignity issues
Body image
Malodour
Exudate
management
Justifying our decisions
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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
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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…….
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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!