Roper-Logan-Tierney Care Plan Essay example

1659 Words May 19th, 2013 7 Pages
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
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(Kozier et al. 2008)

In addition Mr Browns mobility is an extrinsic factor that plays a risk in developing pressure ulcers’ Brown already has pressure ulcer which if we consider his mobility status it causes him to have restricted movement due to pain. If we consider the Waterlow Assessment Mr brown scores of three. Moreover due to immobility Mr Brown is unable to reposition his to relieve pressure.

Moreover the external factor of sheering of the skin occurring when Mr Brown is being repositioned with slide sheets could lead to further risks of pressure sore development. “This is because shearing causes tissue ischaemia by moving vessel laterally and impeding the flow of blood” (Kozier et al.2008)

In addition the intrinsic factor that Mr Brown is diabetic leads the fact that his skin bleeds quick etc REFERENCE

Additionally external factors that effect the mattress
Step 3
Moreover infection can occur in pressure ulcers. In general ‘the ulcer bed plus adjacent tissue are invaded, with cellulitus developing as a result’ (wound care book). This evident due to granulating tissue. Moreover to protect the granulating tissue. Moreover to protect the granulating tissue from becoming infected a dressing should be put in place. If we consider the Tayside wound formulary for dressing pressure ulcers. It suggests for the granulating tissue, that it aim is to promote angiogenesis resulting in

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