Creating a wound care plan for you and your patient can help you to set goals and measure the progress of the wound care you provide. It can also help you to decide when you change your treatment plan if the goals you have set are not being achieved.
Of course, a wound care plan must be made in collaboration with your patient. There is no point in creating a plan of care if your patient is not on board. To this end, it is important that you create goals that are specific, realistic and achievable. If you set goals that are unrealistic, you may lose your patient’s cooperation.
Different facilities will utilize different care planning frameworks (i.e. SOAP or DAPE). They are all similar in that they describe a problem, propose ways to solve the problem, propose interventions and evaluate the response to treatment. Whichever care planning method you use, use it consistently.
The subjective data is what the patient states about their condition. For example, the patient with an infected deep venous ulcer to the lower leg may report pain. They may also report that they feel embarrassed about the odor coming from the wound and worry that others might notice it.
Objective data is the information that you gather when you talk to the patient and examine the wound. In addition to measuring the wound and probing its depth, describing the amount and type of drainage and the type of tissue present (healthy granulation tissue, slough, presence of necrotic tissue), you will also want to take note of the patient’s concerns. You may use various nursing tools during this phase to help you gather the necessary information.
Once you have completed your assessment using all necessary means, it’s time to plan. Start by identifying the problem (s), such as pain and infection. Remember that your goals and the patient’s goals may be different- you may be focused on a reduction in wound size, while your patient is focused only on the pain. You need to work with the patient to formulate specific and measurable goals that can actually be achieved. Remember to be specific!
This is often the area that practitioners become focused on. We sometimes get tunnel vision and see only the wound before us. It’s all about the dressing change and the products we use. To your patient, wound care may represent only pain or discomfort- remember to take your patient’s comfort into consideration.
It’s important to evaluate your progress. Assessment and reassessment using the same tools and methods of assessment each time will help you to evaluate whether you are meeting the goals you set in the planning phase. If the wound has stalled in the healing process, it may be time to consider changing tactics, but it’s also important to allow enough time to see whether a certain treatment will be effective. Signs of progress will encourage both you and your patient towards meeting measurable and specific goals.
Establishing a wound care plan for you and your patient requires collaboration between the two of you. Setting realistic, specific and achievable goals will help you both stay focused to achieve a positive outcome.
If you are interested in learning more about wound care, assessment of wounds and wound care products that can help you succeed in managing your patients’ wounds, you may want to consider wound care certification. We offer comprehensive online training for health care professionals.