Sensory Perceptions
This patient is alert, oriented, and can independently identify and react to discomfort caused by pressure.
What is "No Impairment" (Score 4)?
This patient experiences perspiration that saturates their sheets and clothing continuously. Their incontinence is unmanaged, resulting in constant damp skin.
What is "Constantly Moist" (Score 1)?
This patient independently walks around their room and the unit multiple times a day, engaging in normal daily activities.
What is "Walks Frequently" (Score 4)?
This patient receives less than half of their required nutritional needs through tube feeding or TPN. They consume minimal food and drink, often leaving meals untouched.
What is "Very Poor" (Score 1)?
This patient uses a lift device for transfers and requires minimal assistance. They rarely experience sliding or dragging that would cause skin frictio
What is "No Apparent Problem" (Score 3)?
This patient has mild peripheral neuropathy but responds to discomfort when prompted. They need reminders to reposition themselves.
What is "Slightly Limited" (Score 3)?
This patient is frequently incontinent and needs linen changes at least every 4 hours. Their skin remains wet most of the time.
What is "Very Moist" (Score 2)?
This patient is completely confined to their bed and unable to get up without total assistance.
What is "Bedfast" (Score 1)?
This patient eats only about half of their meals and rarely finishes their protein portion. Their fluid intake is inconsistent, and they rely on supplemental drinks.
What is "Probably Inadequate" (Score 2)?
This patient has severe muscle weakness and cannot reposition themselves. Caregivers often drag the patient during transfers, resulting in redness over bony prominences.
What is "Problem" (Score 1)?
This patient is heavily sedated after surgery and only responds to painful stimuli by grimacing but cannot vocalize or reposition themselves.
What is "Very Limited" (Score 2)?
This patient is occasionally incontinent, with their skin becoming moist around one or two times daily. They do not require frequent linen changes.
What is "Occasionally Moist" (Score 3)?
This patient spends most of their time in a chair and is unable to bear weight or move to another chair without help.
What is "Chairfast" (Score 2)?
This patient consistently eats all their meals, including a balanced intake of proteins, carbohydrates, and fluids. They do not require any supplements.
What is "Excellent" (Score 4)?
This patient moves independently in bed and transfers without sliding or dragging their skin. No assistance is needed to prevent friction injuries.
What is "No Apparent Problem" (Score 3)?
This patient is comatose and completely unresponsive to painful stimuli, including pinching or pressure applied to the skin.
What is "Completely Limited" (Score 1)?
This patient has excessive wound drainage that keeps their dressing and surrounding skin wet most of the time, despite regular changes.
What is "Constantly Moist" (Score 1)?
This patient is able to stand and take a few steps to the bathroom but spends the majority of their day sitting or lying down.
What is "Walks Occasionally" (Score 3)?
This patient eats more than half of most meals and regularly consumes a serving of protein. They drink adequate fluids daily and only occasionally require nutritional supplements.
What is "Adequate" (Score 3)?
This patient occasionally slides down in their bed but is able to assist minimally with repositioning. They require some help to reduce the risk of skin friction during transfers.
What is "Potential Problem" (Score 2)?
This patient has significant neuropathy from diabetes. They only respond to very loud voices or significant pressure and cannot feel discomfort in most parts of their body.
What is "Very Limited" (Score 2)?
This patient is continent and their skin rarely becomes moist, except during routine hygiene care or occasional sweating.
What is "Rarely Moist" (Score 4)?
This patient has a hip fracture and is recovering post-surgery. They can pivot to transfer from bed to chair but require assistance for all further mobility.
What is "Chairfast" (Score 2)?
This patient has severe nausea and vomiting, tolerating only small sips of clear fluids and no solid food for several days. Their nutritional intake is negligible.
What is "Very Poor" (Score 1)?
This patient slides down in their bed or chair frequently, requiring repositioning multiple times a day. They cannot lift themselves independently and experience significant skin friction during transfers.
What is "Problem" (Score 1)?