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Developing a care plan
Once you have done a comprehensive assessment of the patient and wound, you can move on to developing an effective care plan and set specific goals for the treatment.
When developing a care plan for hard to heal wounds, your main focus should be on preventing complications and creating the optimal environment for wound healing, based on the aetiology of the wound.
Remember to involve your patient in this process. As you have probably already experienced yourself – and many studies have already documented – engaging patients directly in their care planning and treatment choices improves their adherence to treatment and ultimately ensures better outcomes.1
Based on you holistic assessment you should adhere to the evidence-based standards of care:
- Treat the underlying causes and gain control of co-morbidities.
- Manage wound tissue through wound preparation (cleansing and debridement).
- Manage wound exudate by managing the gap (the space between the dressing and the wound bed).
- Prevent or treat infection.
How you treat the underlying causes and gain control of co-morbidities will depend on the individual circumstances. The plan should define the path forward and be agreed upon by everyone involved – including the patient and their family.
How often should you assess the wound?
A wound should be assessed at each dressing change – or at least once a week – to make sure the treatment is having the right effect.5
It’s important that you set dressing change frequency against the treatment goals you have defined. For example, if you are managing a highly exuding wound, frequent weekly dressing changes will be necessary; if you are managing a granulating wound, you will usually only need to do a few dressing changes per week. Remember to document the reasons for how often the dressing needs to be changed.
If you observe any of the following:
- a less than a 20% improvement in the wound area over a period of four weeks;
- unexpected increase in exudate;
- suspected infection or biofilm;
- increased pain or a general decline in the patient’s health and wellbeing
… you should always refer the patient to a specialist.1
Care Plan – Checklist:
- The care plan clarifies who is in the multidisciplinary care team.
- The care plan is accessible and understood by all parties participating in the care of the wound.
- The care plan clearly defines the care pathway, including specific treatment of the wound bed, edge and peri wound skin.
- It includes specific wound healing objectives and the patient’s expectations.
- It articulates what to do if the objectives are not reached.
- It identifies risk factors to watch for and instructions on what to do if they arise or are suspected (i.e. early signs of infection, change in wound exudate or wound edge maceration).
- The care plan makes it clear to the patient when to inform their healthcare professional if their wound is not progressing as expected (i.e. warning signs/symptoms of infection).
- It clearly defines when consultation or referral to a specialist
is necessary.
When to refer or consult a specialist
You should reach out to a wound care specialist if:
- The care plan was established and followed but the wound shows no signs of healing progression within 14 days.
- The wound area has decreased less than 20% within 4 weeks.
- There is suspicion or signs of malignancy.
- Worsening of the wound condition is observed through increases in size, odour, pain, or exudate.
- There is deterioration of the wound edge (e.g. advancing, rolling, undermining, maceration) or the periwound skin (e.g. advanced maceration, excoriation and hyperkeratosis).
- There are underlying structures in the wound like exposed bone or tendons.
- The aetiology of the wound is unknown.
- There is suspicion or signs of spreading or systemic infection.
- There is sepsis suspected, then an urgent medical review is required.
- Detrimental biofilm or local infection is suspected, and cleansing or debridement is indicated, but outside of your scope of practice (e.g. conservative sharp debridement).
- There are comorbidity complications (i.e. uncontrolled diabetes, increased blood glucose levels, elevated C-Reactive Proteins, vascular status).
- There is an overall decline in the patient’s health and wellbeing.