Roper-Logan-Tierney Care Plan

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A pressure ulcers is ‘ a localised area of cellular damage resulting from direct pressure on the skin causing ischawmia, or from shearing or friction forces causing mechanical stress on the tissues’ (Chapman and Chapman 1981). Common places for pressure ulcers to occur are over bony prominences, such as the sacral area, heels, hip, and elbow. (NICE 2005) Initially to maintain confidentiality the patient will be referred to as Mr Brown. Mr Brown has given permission for his nursing notes and details to be referred to through out this assignment. He is also aware that is identity will remain unknown and that a false name was chosen for assignment purposes. This can be identified in the NMC Code in ‘respecting people’s right to…show more content…
Moreover the dressing can protect against shearing and friction. Pegasus Step 4 Initially when admitted to hospital the Malnutritional Universal Screening Tool (MUST) is completed within 24 hours of admission throughout NHS Tayside.(NHS Tayside must sheet)MUST is supported by the royal college of nursing and the registered nursing home association. NHS Tayside have adapted their MUST Tool from BAPEN.Bapen is a multi-professional association with its members consisting of the healthcare professionals found in a multi-disiplinary team.(the explanary booklet).The purpose of the MUST Tool is to ‘identify adults who are underweight and at risk of malnutrition,as well as those who are obese.’ There are five steps to using the MUST tool,which can help when completing a careplan.nutrition plays an important role in the assessment of pressure ulcers as inadequate nutrition can lead to delayed recovery and healing time leading to a longer stay in hospital(MUST report 10 key points). The initial step is to measure the height and weight of the patient to calcuylate BMI.This then enables a score to be obtained for step 1. Step 2 identifies the percentage of unplanned weight loss and enables a score to be obtaioned. Step 3 establishes the effect of acute disease,that there has been no nutritional intake. Step 4 consists of adding the scores from steps,2 and 3 together. The higher the score equals a higher risk to malnutrition. Finally Step 5
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