Version June 2024
| Sensory perception | Moisture | Activity | Mobility | Nutrition | Friction & shear |
| Ability to respond meaningfully to pressure-related discomfort | Degree to which skin is exposed to moisture | Degree of physical activity | Ability to change and control body position | Usual food intake pattern | |
| 1. Completely limited | 1. Constantly moist | 1. Bedfast | 1. Completely immobile | 1. Very poor | 1. Problem |
|
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR Limited ability to feel pain over most of body |
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. | Confined to bed | Does not make even slight changes in body or extremity position without assistance |
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR Is NPO and/or maintained on clear liquids or IV's for more than 5 days |
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. |
| 2. Very limited | 2. Very moist | 2. Chairfast | 2. Very limited | 2. Probably inadequate | 2. Potential problem |
|
Responds only to painful stimuli Cannot communicate discomfort except by moaning or restlessness OR Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body |
Skin is often, but not always moist. Linen must be changed at least once a shift. | Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. | Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently |
Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding |
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or good position in chair or bed most of the time but occasionally slides down. |
| 3. Slightly limited | 3. Occasionally moist | 3. Walks occasionally | 3. Slightly limited | 3. Adequate | 3. No apparent problem |
|
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities |
Skin is occasionally moist, requiring an extra linen change approximately once a day | Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. | Makes frequent though slight changes in body or extremity position independently |
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered. OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs |
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. |
| 4. No impairment | 4. Rarely moist | 4. Walks frequently | 4. No limitation | 4. Excellent | |
|
Responds to verbal commands Has no sensory deficit which would limit ability to feel or voice pain or discomfort |
Skin is usually dry, linen only requires changing at routine intervals | Walks outside room at least twice a day and inside room at least once every two hours during waking hours | Makes major and frequent changes in position without assistance | Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. | |
| Score: __________ | Score: __________ | Score: __________ | Score: __________ | Score: __________ | Score: __________ |
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