Guest Post by Rick Redfield, PA-C
One of the most effective ways for wound care professionals to effectively help patients experience the best possible environment to heal their wounds is to develop an individualized plan of care.
A wound care plan provides a set of goals to track the progress of the healing process of the wound. Nursing care plans are built around defined patient problems. There are standard nursing diagnoses to define these problems with many resources available to help develop an effective plan. All good care plans should include certain basic elements. Here are the steps of the nursing care plan process as well as how each step should be addressed when creating a care plan:
· Assessment: Data is collected from many sources, such as the medical record, a comprehensive nursing physical assessment (including ADLs or Activities of Daily Living—such as bathing, transferring dressing, feeding and toileting), existing available documentation about your patient’s medical diseases/conditions, which informs about the signs and symptoms of their problems, and interviews with the patient and family. It is important to listen carefully to the patient to fully understand their perception of their issues.
· Identification of patient’s specific problem(s): This is where your findings should be matched to established nursing diagnosis as best as possible. Much work has been done to codify this process in a logical, consistent manner.
· Planning: This is where you define measurable goals/outcomes and nursing interventions specific to the patient’s problems.
· Implementation: The care plan steps are applied to the daily care of the patient and drive the process in an organized, logical process.
· Evaluation: This is a very important step as you regularly re-evaluate the patient to determine if goals/outcomes have been met. If a patient is not improving, the plan must be revised to address the issues and to seek more effective interventions.
The plan must engage the most important partner in the healing process: the patient. An effective wound care plan involves and informs the patient on the progress of their healing. If the patient accepts and abides by the plan it will greatly increase the chances of a good outcome. Developing a plan also provides the patient and the patient’s family with necessary communication. This creates a highly effective team environment that will improve the effectiveness of the care you provide.
Although the process of developing a plan may be comprehensive and well thought out, a wound care plan must set realistic goals if it is to be effective in delivering the best possible care to the patient and their family. A poorly-written plan can result in the patient becoming discouraged by the progress of the treatment. This is why reassessments of the plan with all parties should be done on a regular basis
The methodology of the wound care plan largely depends on the facility. The framework of the plan matters less than the content. Make sure that the problem is clearly defined, that a specific treatment is identified and that a timeline is established prior to implementing the plan. It is also important to identify how the treatment will be evaluated and possible interventions if a certain course of treatment fails to deliver the intended results.
One of the most important aspects of wound care is engaging and gaining the support of the patient. Developing a wound care plan helps wound care professionals to assess their patient’s wounds and communicate the care plan to the patient.
Rick Redfield is Director of Clinical Affairs at Telemedicine Solutions, LLC, which provides WoundRounds, the leading wound care outcomes solution.
