Show:
SENSORY PERCEPTION
MOISTURE
MOBILITY
NUTRITION
FRICTION & SHEAR
or
ACTIVITY
100
Ability to respond meaningfully to pressure-related discomfort
What is the Risk Factor/ Subset of SENSORY PERCEPTION
100
Degree to which skin is exposed to moisture
What is the Risk Factor/ Subset of MOISTURE
100
Ability to change and control body position
What is the Risk Factor/ Subset of MOBILITY
100
Usual food intake pattern
What is the Risk Factor/ Subset of NUTRITION
100
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 at all times.
What is FRICTION & SHEAR score of 3 – NO APPARENT PROBLEM
200
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 surface.
What is SENSORY PERCEPTION score of 1. COMPLETELY LIMITED
200
Skin is usually dry. Linen only requires changing at routine intervals.
What is MOISTURE score of 4 - RARELY MOIST
200
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
What is MOBILITY score of 2 – VERY LIMITED
200
Eats over half of most meals. Eats a total of 4 services of protein each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.
What is NUTRITION score of 3 – ADEQUATE
200
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
What is FRICTION & SHEAR score of 1 – PROBLEM
300
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 ½ of body
What is SENSORY PERCEPTION score of 2. VERY LIMITED
300
Skin is occasionally moist, requiring an extra linen change approximately once a day.
What is MOISTURE score of 3 – OCCASIONALLY MOIST
300
Makes major and frequent changes in position without assistance.
What is MOBILITY score of 4 – NO LIMITATIONS
300
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 services or less of protein per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IVs for more than 5 days.
What is NUTRITION score of 1 – VERY POOR
300
Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down.
What is FRICTION & SHEAR score of 2 – POTENTIAL PROBLEM
400
Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
What is SENSORY PERCEPTION score of 3 – SLIGHTLY LIMITED
400
Skin is often, but not always, moist. Linens must be changed at least once a shift.
What is MOISTURE score of 2 – VERY MOIST
400
Makes frequently though slight changes in body or extremity position independently.
What is MOBILITY score of 3 – SLIGHTLY LIMITED
400
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.
What is NUTRITION score of 4 - EXCELLENT
400
Degree of physical activity
What is the Risk Factor/ Subset of ACTIVITY
500
Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
What is SENSORY PERCEPTION score of 4 - NO IMPAIRMENT
500
Skin is kept moist almost constantly be perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
What is MOISTURE score of 1 – CONSTANTLY MOIST
500
1 – Completely Immobile Does not make even slight changes in body or extremity position without assistance.
What is MOBILITY score of 1 – COMPLETELY IMMOBILE
500
Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 services 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
What is NUTRITION score of 2 – PROBABLY INADEQUATE
500
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
What is ACTIVITY score of 3 – WALKS OCCASIONALLY