National best practice and evidence based guidelines for wound ...

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N at i o N a l b e s t p r ac t i c e a N d e v i d e N c e b a s e d g u i d e l i N e s f o r w o u N d m a N ag e m e N t 76 Appendix 4: MUST Tool (continued) BAPEN Advancing Clinical Nutrition 'Malnutrition Universal Screening Tool' (‘MUST’) Alternative measurements and considerations Step 1: BMI (body mass index) If height cannot be measured Use recently documented or self-reported height (if reliable and realistic). If the subject does not know or is unable to report their height, use one of the alternative measurements to estimate height (ulna, knee height or demispan). If height & weight cannot be obtained Use mid upper arm circumference (MUAC) measurement to estimate BMI category. Step 2: Recent unplanned weight loss If recent weight loss cannot be calculated, use self-reported weight loss (if reliable and realistic). Subjective criteria If height, weight or BMI cannot be obtained, the following criteria which relate to them can assist your professional judgement of the subject’s nutritional risk. 1. BMI Clinical impression – thin, acceptable weight, overweight. Obvious wasting (very thin) and obesity (very overweight) can also be noted. 2. Unplanned weight loss Clothes and/or jewellery have become loose fitting (weight loss). History of decreased food intake, reduced appetite or swallowing problems over 3-6 months and underlying disease or psycho-social/physical disabilities likely to cause weight loss. 3. Acute disease effect No nutritional intake or likelihood of no intake for more than 5 days. Further details on taking alternative measurements, special circumstances and subjective criteria can be found in The ‘MUST’ Explanatory Booklet. A copy can be downloaded at www.bapen.org.uk or purchased from the BAPEN office. The full evidence-base for ‘MUST’ is contained in The ‘MUST’ Report and is also available for purchase from the BAPEN office. BAPEN Office, Secure Hold Business Centre, Studley Road, Redditch, Worcs, B98 7LG. Tel: 01527 457 850. Fax: 01527 458 718. bapen@sovereignconference.co.uk BAPEN is registered charity number 1023927. www.bapen.org.uk MAG Malnutrition Advisory Group A Standing Committee of BAPEN BAPEN is registered charity number 1023927 www.bapen.org.uk © BAPEN 2003 ISBN 1 899467 85 8 Price £2.00 All rights reserved. This document may be photocopied for dissemination and training purposes as long as the source is credited and recognised. Copy may be reproduced for the purposes of purposes of publicity and promotion. Written permission must be sought from BAPEN if substantial reproduction or adaptation is required. Published November 2003 by MAG the Malnutrition Advisory Group, a Standing Committee of BAPEN. Review date December 2004 and annually thereafter. ‘MUST’ is supported by the British Dietetic Association, the Royal College of Nursing and the Registered Nursing Home Association.
BAPEN Advancing Clinical Nutrition 'Malnutrition Universal Screening Tool' (‘MUST’) Alternative measurements: instructions and tables MAG Malnutrition Advisory Group A Standing Committee of BAPEN If height cannot be obtained, use length of forearm (ulna) to calculate height using tables below. (See The ‘MUST’ Explanatory Booklet for details of other alternative measurements (knee height and demispan) that can also be used to estimate height). Estimating height from ulna length HEIGHT (m) HEIGHT (m) HEIGHT (m) HEIGHT (m) Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible). Men (65 years) 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 Ulna length (cm) 32.0 31. 5 31.0 30. 5 30.0 29. 5 29.0 28.5 28.0 27.5 27.0 26.5 Women (65 years) 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.66 Estimating BMI category from mid upper arm circumference (MUAC) The subject’s left arm should be bent at the elbow at a 90 degree angle, with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process). Mark the mid-point. Ask the subject to let arm hang loose and measure around the upper arm at the mid-point, making sure that the tape measure is snug but not tight. If MUAC is < 23.5 cm, BMI is likely to be 32.0 cm, BMI is likely to be >30 kg/m 2 . BAPEN is registered charity number 1023927 www.bapen.org.uk 1.73 1.71 1.68 1.67 26.0 25.5 1.68 1.66 1.65 1.63 Men (65 years) 1.65 1.63 1.62 1.60 1.59 1.57 1.56 1.54 1.52 1.51 1.49 1.48 1.46 1.45 Ulna length (cm) 25.0 24. 5 24.0 23. 5 23.0 22. 5 22.0 21. 5 21.0 20. 5 20.0 19. 5 19.0 18.5 Women (65 years) 1.61 1.60 1.58 1.56 1.55 1.53 1.52 1.50 1.48 1.47 1.45 1.44 1.42 1.40 77
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National best practice and evidence
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Foreword The development of HSE nat
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The management of diabetic foot dis
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These guidelines have been endorsed
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Section 3 - Clinical Guidelines 25-
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Section 4 References and Appendices
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SECTION 1: Background and Justifica
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anked operations of the skin and su
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The number of adults diagnosed with
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On Society The loss to society due
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1.3 Terms of Reference ● To ensur
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SECTION 2: Methodology 21
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2.2 Outline of the grading method u
Page 27 and 28: SECTION 3: Clinical Guidelines 25
Page 29 and 30: 3.2 Principles of Wound Management
Page 31 and 32: Wound Dressings ● The integrity o
Page 33 and 34: ● Removal of devitalised tissue c
Page 35 and 36: 3.4 Guidelines for management of ar
Page 37 and 38: 3.5 Guidelines for the prevention a
Page 39 and 40: Table 10: Patient Education Inspect
Page 41 and 42: Evaluation ● If one or more pedal
Page 43 and 44: ● Alteration in skin condition in
Page 45 and 46: 3.7 Repositioning for the Preventio
Page 47 and 48: 3.8 Support Surfaces General Statem
Page 49 and 50: SECTION 4: References and Appendice
Page 51 and 52: Graham, I.D., Harrison, M.B., Nelso
Page 53 and 54: Appendices 1. Glossary of Terms 2.
Page 55 and 56: ● Bulla/Bullae: Another term for
Page 57 and 58: ● Granulation: During the prolife
Page 59 and 60: ● Periwound: The area immediately
Page 61 and 62: Appendix 2: Examples of Wound Asses
Page 63 and 64: date odour None on dressing change
Page 65 and 66: Anatomical chart Please mark the ar
Page 67 and 68: Date WOUND DIMENSIONS Max. length m
Page 69 and 70: Date Time THE ADELAIDE & MEATH HOSP
Page 71 and 72: BRADEN SCALE FOR PREDICTING PRESSUR
Page 73 and 74: I need permission for: Name: Title:
Page 75 and 76: BAPEN 'Malnutrition Universal Scree
Page 77: BAPEN Weight before weight loss (kg
Page 81 and 82: AUDIT TOOL for NATIONAL WOUND MANAG
Page 83 and 84: Objective Statement 4 identify shor
Page 85 and 86: Objective Statement 10 identify sho
Page 87 and 88: Treatment Statement 16 in persons a
Page 89 and 90: Objectives Statement 23 the use of
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