Mary Walden, MSN, CWOCN
STEP 3: PROGNOSIS AND GOALS
Once the diagnosis is established, the clinician predicts, or prognoses, the expected outcome and selects an intervention.
Prognosis is defi ned as a prediction of the maximal improve- ment expected from an intervention and how long it will take.
It is thus a useful tool for goal setting. Prognosis may also include prediction of improvement at different intervals during treatment.5
A patient with an insensitive foot due to neuropathy would be a candidate for physical therapy because this condition would constitute a medical necessity, requiring the skills of a physi- cal therapist. The physical therapist would predict a functional outcome of risk reduction following interventions of pressure elimination and stimulation, leading to healing.
In both cases, the ulcerations are related to underlying medical pathology. In the former case, the ulcer would not be expected to respond unless the underlying pathology were addressed. In the latter case, ulcer management would be appropriate, along with risk reduction management. As you can see, the interpretation of the data from the history and physical examination sets the stage for functional diagnosis and allows for triage of cases that should be referred or managed conservatively.
Examination: Part 2
This part of the examination strategy looks at four key features of the wound assessment:
• Evaluation of the surrounding skin
• Assessment of the wound tissue
• Observation of wound drainage
• Size measurements
The sequence of the examination depends on visual obser- vation and palpation of the impaired tissues. Be sure to choose tests and measures that are specifi c to the wound situation. For example, temperature testing may be the best way to distinguish the presence of infl ammatory processes in pressure ulcers in patients with darkly pigmented skin. A wound tracing may be the best method to measure the irregular shape of a venous ulcer.
After completing the examination portion of the diagnostic process, your task is to interpret the physiologic and anatomic systems information and wound assessment data, bringing all of the information together like the pieces of a puzzle to develop a functional diagnosis.2
Evaluation and Diagnosis
The evaluation aspect of the wound care process involves anal- ysis of the fi ndings you have collected. The purpose of evalua- tion is to draw conclusions about a patient’s specifi c problems and needs so that you can implement effective interventions. In short, evaluation leads to clinical judgments.
“Diagnosis” refers to the process itself, as well as the conclu- sion reached after the evaluation data have been organized.3
Diagnosis involves forming a clinical judgment by iden- tifying a problem—that is, a disease/condition or human response—through the scientifi c evaluation of signs and symp- toms, history, and diagnostic studies. Problem identifi cation is a process of diagnostic reasoning in which judgments, decisions, and conclusions are made about the data collected to deter- mine whether intervention is needed.4 Thus, in many respects, a diagnosis is analogous to a research hypothesis: A research hypothesis directs the research study, and a diagnosis directs the patient’s care plan. Both a research hypothesis and diag- nosis are chosen based on available data and information, and both can be proven correct or incorrect as the study or care plan progresses.
Both nurses and physical therapists base diagnoses on the symptoms or the sequelae of the injurious process, such as
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Long-term goals were those predicted to be met by the time of discharge. There has also been a shift in terminology away from using the term goal and replacing it with expected outcome.
In contrast, an outcome is the actual result or status after the intervention.
Completing the wound care process with recommendations is one outcome of physical therapy services. Physical therapists target specifi c, measurable outcomes for specifi c interventions.
To make them functional outcomes, they must meet the cri- teria described below. Target outcomes are short-term, specifi c expectations of a change in impairment status. Since a progno- sis is the expected outcome after a course of care, it represents the long-term goal.
Examples of wound healing prognoses include the following:
1. Ideally healed closure 2. Acceptably healed closure 3. Minimally healed closure 4. Clean and stable open wound 5. Wound ready for surgical closure 6. Not expected to improve
Evaluation of Progress and Outcomes
As just noted, an outcome is the result of what is done, that is, the change resulting from an intervention. Outcomes are mea- sured using performance indicators, objective measurements used to monitor change resulting from an intervention. Providers, payers, regulators, and clinicians all work toward establishing reliable performance indicators to report clinical outcomes.
Exhibit 1.1 lists examples of wound-related performance indica- tors, with outcomes and functional outcomes for each.
Two types of outcomes are behavioral and functional. Payer groups have an interest in both types.8 Thus, we’ll discuss each in detail shortly.
Reporting Outcomes
The reporting of outcomes is not to be confused with process;
that is, an intervention or activity performed to achieve a result.
Outcomes must be specifi c, realistic, time oriented, objective, patient centered, and measurable. Once established, outcomes serve as an evaluation tool.
Terms Frequently Misused When Reporting Outcomes This section discusses some terms that are commonly misused when reporting outcomes, and the appropriate way to report an outcome.
Reduced risk of infection is a topic of confusion, and clinicians must understand that it is not an outcome. Freedom from infection or reduction in exudate, odor, or culture results are measur- able outcomes. For any of these outcomes to be functional outcomes, they must change the way the body system func- tions. Freedom from infection can be an outcome of wound cleansing, but it becomes a functional outcome when wound healing progresses to the next phase of repair. The functional outcome would be correctly written as, “The wound is infec- tion-free, and the wound healing has progressed from the infl ammatory phase to the proliferative phase.”
A troublesome word in healthcare is maintained, which implies no change. Controlled should not be mistaken for main- tained. For example, if edema has fl uctuated from treatment Some clinicians are intimidated by the idea of predicting
outcomes; however, they are in the best position to do so if they are knowledgeable about the effects of the interventions prescribed and administered. Patients would not expose them- selves to interventions with unpredictable results, and payers would not reimburse providers for services with unexpected benefi ts and indefi nite costs. In the current health-care envi- ronment, a sound understanding of prognosis and outcomes is important for all health-care practitioners.
Wound Prognosis Options
The prognosis options for wounds are limited. One system for evaluating wound healing defi nes healing as minimally, accept- ably, or ideally healed. An ideally healed wound results in return of the fully restored dermis and epidermis with intact barrier function. An acceptably healed wound has a resurfaced epithe- lium capable of sustained functional integrity during activi- ties of daily living. A minimally healed wound is characterized by closure but without a sustained functional result and may recur. In all these defi nitions, complete closure of the wound is expected.7
For some individuals and some wounds, closure is not an option. Rather, the best prognosis is a change in the wound healing phase from an impaired or early phase of repair to a more advanced phase of repair. A change in wound healing phase is a functional outcome prediction. This method moni- tors a real change in the organ function of the skin and soft tissues, which is a measure of reduced functional impairment.
The prognosis that a wound is not expected to improve should lead to referral for other management. Nurses may be expected to care for the wound, but the patient may need ser- vices including palliative care that can be provided by a physical therapy, dietary, or orthotic intervention.
Goals
A goal is precisely defi ned as the desired or expected result of an intervention. Goal setting differs somewhat for different clini- cal disciplines involved in wound care. Here we are limiting the discussion of goal setting to the disciplines of nursing and physical therapy. Other disciplines would have similar goals that apply to their area of expertise.
Nursing Goals
Nurses must set priorities, establish goals, and identify desired outcomes for patients. Goals are important because they assist in determining outcomes of care and measuring the effective- ness of interventions. Goals must be measurable, objective, and based on the prioritized needs of the patient.
Short-term goals are typically actions that must be taken before a patient is discharged or moved to another level of care.
Long-term goals may require continued attention by a patient and/or caregiver long after discharge. Short-term goals should move a patient toward the long-term goal.
Physical Therapy Goals
Physical therapists are also required to establish short-term and long-term goals. These goals should be measurable, objective, functional, and very specifi c. Traditionally, a short-term goal was one that would be achieved in 30 days or less and usually corresponded to the end of the billing period or length of stay.
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Examples of Performance Indicators with Wound Outcomes and Functional Wound Outcomes Performance Indicators Wound Outcomes Functional Wound Outcomes 1. Change in wound and
surrounding skin attributes
Progression through the phases of wound healing (infl ammation, proliferation, and epithelialization)
1. Clean, stable wound ready for surgical closure
2. Reduced severity of wound in depth or size
2. Dressing changes needed biweekly instead of daily 3. Change in wound
exudate characteristics or undermining
3. Exudate managed; patient returns to work
4. Closure 4. Return to work/leisure activities
1. Temperature comparison Oxygenation or perfusion of tissue
1. Progress to next wound healing phase 2. Transcutaneous partial
pressure of oxygen level
2. Pain level no longer interferes with ADL 3. Laser Doppler
1. Girth measurements Edema reduced or controlled 1. Patient able to don compression hose 2. Volume meter measurements 2. Leg ulcers are smaller, require less frequent
dressing changes 3. Palpation grading system
1. Wound exudate characteristics Infection controlled 1. Wound exudate odor controlled, able to return to community
2. Wound and surrounding skin attributes
2. Pain alleviated, patient resumes walking 3. Culture
1. Free of necrosis Clean, stable wound 1. Frequency of visits reduced 2. Proliferation phase tissue
attributes
2. Physical therapy intervention no longer required
3. Change in depth or size 3. Patient can now manage wound dressings changes 1. Braden Scale score Reduced risk of pressure
ulceration
1. Repositions self in bed 2. Functional activities
performance
2. Patient performs self-care activities while in wheelchair
3. Comprehension testing 3. Patient demonstrates use of hand mirror to
monitor skin
1. Wound closure Acceptable healed scar 1. Patient identifi es risk factors for reulceration 2. Functional activities performed
related to use of scar tissue
2. Patient uses protective equipment correctly under scar tissue to perform functional activities in wheelchair
EXHIBIT 1.1
to treatment, and then stabilizes as a result of intervention, the outcome is that edema is controlled. A functional out- come for controlled edema would be stated as, “The edema in the tissues surrounding the wound is controlled.” The functional outcome of control of the edema is that the wound progresses to the next phase of healing.
Maximized and minimized are similarly confused with outcomes.
For example, “maximized participation in activities of daily living” does not refl ect the functional outcome of an interven- tion with an orthotic device. A functional outcome reports the result of the intervention, such as, “The patient performs activities of daily living wearing/using orthotic equipment,
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To constitute a functional outcome, the results must meet three criteria9:
1. The result is meaningful.
2. The result is practical.
3. The result can be sustained over time outside the treatment setting.
Meaningful is defi ned as being of value to the patient, caregiver, or both. Practical means that the outcome is applicable to the patient’s life situation. Sustainable over time refers to functional abilities achieved through an intervention that are maintained by the patient or caregiver outside the clinical setting (e.g., a patient demonstrates the ability to apply a dressing and stock- ing during two follow-up visits).10
Standardized tests and measurement tools are useful to monitor and track change over time. The Bates-Jensen Wound Assessment Toll (BWAT), formerly called the Pressure Sore Status Tool (PSST), the Sussman Wound Healing Tool (SWHT), and the Pressure Ulcer Scale for Healing ( PUSH), described in Chapter 4, can be used to document the outcomes of changes in wound attributes by changes in test scores, and can then be applied to function. For example, using the BWAT to moni- tor exudate amounts, a change in score on that test item from 4 (moderate exudate) to 2 (scant exudate) would indicate reduced drainage. This outcome is measurable and objective, and meets the criteria for a valid outcome. However, this informa- tion alone does not constitute a functional outcome. To interpret this score as a functional outcome, a statement must connect the fi ndings with meaning to the patient, practical effect, and sustain- able result. A correct statement of functional outcomes would be, “Wound exudate BWAT has reduced from 4 (moderate) to 2 (scant) exudate, patient demonstrates ability to monitor for signs of infection and action to take, and patient is now able to return to work and will be seen for intermittent follow-up.”
Functional outcomes should be documented throughout the course of care, not just at discharge. Factors you can use to demonstrate intermittent functional change include change in patient lifestyle, change in patient safety, and adaptation to impairment or disability. These statements should be patient centered and measurable (Exhibit 1.2).
and has returned to work and/or resumed leisure activities.”
An example of misuse of minimized as an outcome is “mini- mized stresses precipitating or perpetuating injury.” Correct use is, “Functional outcome—patient/caregiver identifi ed stress-reduction methods to minimize risk of injury.”
Improved is defi ned as “to make better or enhance in value.”
This is a subjective measure, not a measurable outcome. An outcome reports the objective result of improvement. For example, increased vital capacity measured in liters (perfor- mance indicator) is a measurable change in the pulmonary system, with a result of increased oxygenation of tissues for wound healing. The functional outcome is “wound pro- gresses to next phase of healing.”
Provided is sometimes confused with an outcome, although it is an action by the clinician, not an outcome of the inter- vention. An example of improper use is “provided electri- cal stimulation to enhance circulation.” This describes the rationale for the intervention, not the outcome.
Promoted is another inappropriately used term. For example,
“promoted angiogenesis” is a process. Angiogenesis is an expected outcome of treatment and represents an attribute of wound healing. The performance indicators of angiogen- esis are change in wound attributes, phase, or size. The out- come is wound progression through the proliferative phase.
Behavioral Outcomes
Behavioral outcomes include behaviors that can be observed or monitored to determine whether an acceptable or positive out- come is achieved within the desired time frame. Like all out- comes, behavioral outcomes must be specifi c, realistic, time oriented, objective, patient centered, and measurable.
Use measurable action verbs to describe behavioral out- comes. For example, the verb understand is not measurable; we cannot measure a person’s understanding. The same is true for the verbs feel, learn, know, and accept. But identify is measur- able; the patient can be tested to determine whether he or she can identify. Other appropriate action verbs include list, record, name, state, describe, explain, demonstrate, use, schedule, differ- entiate, compare, relate, design, prepare, formulate, select, choose, increase, decrease, stand, walk, and participate.
Examples of behavioral outcomes for a patient with a wound include: “The patient will describe the signs of wound infection and identify correct action within 24 hours” and “The patient will demonstrate wound dressing application within 2 days.”
Correct documentation that the target outcome was met would include: “Patient is able to describe the signs of infection and list the steps for corrective action. Patient is able to demonstrate correct wound dressing application.”
Functional Outcomes
A functional outcome helps to communicate a change in func- tion to the patient, caregiver, and payer. Physical therapists usu- ally work with patients who have experienced loss of functional abilities, and they use functional tests that measure physical attributes to predict the function that the patient is expected to achieve after a course of treatment. Function in this context refers to activities and actions that are meaningful to the patient or caregiver. You should make a determination about mean- ingful function while completing the “reason for referral” por- tion of the assessment.
Example of Functional Outcomes Documented Throughout Course of Care
Initial Statement: Patient is unable to sit in wheelchair without trauma to integument.
Initial Target Outcome: Patient is sitting for 2 hours in adaptive seating system in 2 weeks.
Interim Outcome After 1 Week: Patient sits for 1 hour in adaptive seating system.
Discharge Statement: Patient sits in adaptive seating system for 2 hours without disruption of integumentary integrity.
EXHIBIT 1.2
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How to Write Outcome Statements and Functional Outcomes When reporting outcomes, use the following guidelines:
1. An outcome expresses the result of an intervention—not the intervention or the process—to reach an outcome (e.g., wound resurfacing/closure).
2. A behavioral outcome can be learned information (e.g., demonstrates application of wound dressing). This outcome would follow an intervention of instruction.
3. Coordination of treatment including: interdisciplinary, communication, and documentation of care outcomes used to ensure proper utilization management include.
Functional outcomes are written to describe results of treatment on function and include three parts:
1. Description of a meaningful functional change to a body system (e.g., progression through the phases of healing) 2. Description of a practical result of a change in a body system (e.g., wound is minimally exudative)
3. Description of the sustainable result or change in the impairment status or disability resulting from the intervention (e.g., pressure elimination allows the patient to sit up in wheelchair 2 hours twice a day)
EXHIBIT 1.3
A change in wound tissue attributes and size can also be used as a functional outcome; for example, “Free of necrosis, reduced risk of infection, and size reduced 50%, wound is clean and stable, decreased frequency of visits required” (Exhibit 1.3).