1. Nursing Plans of Care Keith Hampton, MSN, APRN, ACNS-BCMU
Keith Hampton, MSN, APRN, ACNS-BC
Nicole Webb, APRN, DNP
Cameron Johnson, Application Analyst
Melissa Pickett, APRN, ACNS-BC, CWOCN
Gayla D. Maier, RN, BSN, ONC, WCH Facility Nurse Educator

2. Pressure Ulcer Prevention Plan
Originally started as a Lighthouse project
Based on the Braden total risk score
Pros:
Short plan of care
Cons:
Pre-determined set of interventions
Was not an individualized plan of care
Was not outcome driven
Not in line with current literature on Braden

3. Pressure Ulcer Prevention
The story of a patient
Melissa Pickett & Gayla Maier

4. Pressure Ulcer Prevention Plan
Current Plan of Care
Goals are based on the Braden sub scale scores
Cons:
More interventions than the Lighthouse Plan of Care
Pros:
Can be individualized to the patients needs
I-view charting will trigger the pre-determined met vs not met goals based on documentation
The interventions for the care plan goals can be charted in I-view or from the care plan screen
Based on current literature related to use of the Braden Tool

5. Braden Total Score Braden Subscales
Interventions are grouped, based on level of risk
“cookie cutter plan of care”
Example:
Total risk score of 19
Interventions:
Did not trigger based on total Braden Score.
No Interventions Initiated
Interventions are based on the individual clinical factors that encompass that sub scale
“individualized plan of care”
Example:
Next slide…….

6. Braden Sub Scales Total Braden Risk Score 19 Subscale scores
Sensory Perception 4
Moisture 4
Activity 3
Mobility 2
Nutrition 3
Friction & Shear 3

7. This patient developed a Stage III pressure ulcer
Problems:
Braden total score only was taken into consideration with regards to nursing interventions
No evidence (no documentation) of any teaching, efforts to reposition patient or other interventions prior to developing the pressure ulcer
Clinical factors were not taken into consideration
Pain scale score greater than 4 which was preventing her from repositioning self
Co-morbidities were also not considered

8. Current Pressure Ulcer Prevention Plan of Care
A subscale of less than 4 or 3 (for friction and shear) would have triggered an unmet goal requiring the nurse to chart an intervention
Interventions on education are in this care plan
Pain is addressed with this care plan
This care plan could have been further individualized to better meet this patient’s needs

9. What Barbara Braden say about subscales scores?
Barbara Braden, presentation from WOCN conference 2010 says:
“Each subscale score serves as…. 1. initial appraisal of patients specific problems and functional deficits, 2. flag for assessments that need to be explored further, 3. a guide to the types of interventions that may be required”
“Total scores and levels of risk serve as…. 1. an estimate of the probability that a pressure ulcer will occur, 2. a guide to the intensity of the interventions that should be used”

10. What does the literature say about subscale scores?
“Assessing patient risk of developing a PU does little good for the patient or the institution unless information from that assessment is linked to effective preventive interventions.”
Bolton, L. (2007). Which pressure ulcer assessment scales are valid for use in the clinical setting? Journal of Wound Ostomy Continence Nursing, 34,

11. How were care plan interventions chosen?
From our skin management protocol
Evidence Based

12. References
Detroit Medical Center, Wayne State University. Using the Braden Scale in clinical practice (CD-ROM). (2004)
Bolton, L. (2007). Which pressure ulcer assessment scales are valid for use in the clinical setting? Journal of Wound Ostomy Continence Nursing, 34,
Braden, Barbara. (2010). WOCN Conference, powerpoint presentation. The Braden Scale. Reflections and Insights after 25 years.
Bryant, R. A. & Nix, D. P. Acute & chronic wounds. Current management concepts. 4th ed. (2012). St.Louis, MO:Elsevier, Mosby
Noonan, C., Quigley, S. & Curley. Using the Braden Q Scale to predict pressure ulcer risk in pediatric patients. (2011). Journal of Pediatric Nursing, 26,
Wound Ostomy and Continence Nurses Society (WOCN). (2010). Guideline for Prevention and Management of Pressure Ulcers (2). Mount Laurel, New Jersey: WOCN.
National Pressure Ulcer Advisory Panel (NPUAP). (2009). Pressure ulcer prevention & treatment. Quick reference guide.

13. Pressure Ulcer Prevention Plan of Care
Nicole Webb & Cameron Johnson

14. Goals Continue Lighthouse Project
Complete Pressure Ulcer Prevention Plan of Care
Complete Wound Plan of Care
Develop top DRGs based on this model
This will occur for entire MU enterprise
Develop patient-centered Plans of Care
Paste statement from internal review here

15. Care Plans Power Orders Folder

16. Care Plan Power Orders Folder, cont’d

17. Icons
Note each one
Icons have specific meaning

18. Pressure Ulcer Prevention Plan of Care
Outcomes

19. Outcomes
Can select or un-select components by checking or un-checking the boxes

20. Click the document in plan tab

21. Nurse can click the boxes for “quick” charting

22. Note Negative and positive responses

23. Pressure Ulcer Prevention IPOC
Interventions

24. Interventions

25. Demo of patient-centered goals

26. Patient-Centered Goals
1. Add to Phase
2. Choose Outcome/Intervention
3. Choose Patient-specific

27. Patient-centered goal, cont’d
Type in the word “patient” and click Search
You can then pick the goal and/or intervention
Type in the (free-text) the patient’s goal and/or intervention

28. Care Plan Timeline

29. Closing Remarks
Keith Hampton

30. Closing Remarks and Questions