Sensory Perception i Ability to respond meaningfully to pressure-related discomfort. 1 - Completely Limited: Unresponsive to painful stimuli; limited sensation over most of body 2 - Very Limited: Responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness 3 - Slightly Limited: Responds to commands but cannot always communicate discomfort; impairment in 1-2 extremities 4 - No Impairment: Responds to verbal commands; no sensory deficit limiting ability to feel or voice pain
Moisture i Degree to which skin is exposed to moisture. 1 - Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, or other fluids 2 - Often Moist: Skin is often but not always moist; linen must be changed at least once per shift 3 - Occasionally Moist: Skin is occasionally moist; requires extra linen change approximately once per day 4 - Rarely Moist: Skin is usually dry; linen only requires changing at routine intervals
Activity i Degree of physical activity. 1 - Bedfast: Confined to bed 2 - Chairfast: Ability to walk severely limited or nonexistent; must be assisted into chair or wheelchair 3 - Walks Occasionally: Walks occasionally during the day but for short distances; spends majority of each shift in bed or chair 4 - Walks Frequently: Walks outside the room at least twice a day and inside the room at least once every 2 hours during waking hours
Mobility i Ability to change and control body position. 1 - Completely Immobile: Does not make even slight changes in body or extremity position without assistance 2 - Very Limited: Makes occasional slight changes but unable to make frequent or significant changes independently 3 - Slightly Limited: Makes frequent though slight changes in body or extremity position independently 4 - No Limitations: Makes major and frequent changes in position without assistance
Nutrition i Usual food intake pattern. 1 - Very Poor: Never eats a complete meal; rarely eats more than one-third of any food offered; eats only 2 servings of protein per day 2 - Probably Inadequate: Rarely eats a complete meal; generally eats about half of any food offered; protein intake includes only 3 servings per day 3 - Adequate: Eats over half of most meals; eats a total of 4 servings of protein (meat and dairy) each day 4 - Excellent: Eats most of every meal; never refuses a meal; usually eats 4 or more servings of meat and dairy products
Friction and Shear i Friction occurs when skin moves against support surfaces; shear occurs when the skeleton moves while the skin stays still. 1 - Problem: Requires moderate to maximum assistance in moving; complete lifting without sliding against sheets is impossible 2 - Potential Problem: Moves feebly or requires minimal assistance; skin probably slides to some extent against sheets or devices during moves 3 - No Apparent Problem: Moves in bed and chair independently and has sufficient muscle strength to lift up completely during a move