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Patient's Name:_______________________________Evaluator's Name:_______________________________Date of Assessment:___________________

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Ability to respond meaningfully to pressure-related discomfort

1. Completely Limited:

Unresponsive (does not moan, flinch or gasp) to painful stimuli due to diminished level of consciousness or sedation


Limited ability to feel pain over most of body surface.

2. Very Limited:

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.


Has a sensory impairment that limits the ability to feel pain or discomfort over half of body.

3. Slightly Limited:

Responds to verbal commands but cannot always communicate discomfort or need to be turned.


Has some sensory impairment that limits ability to feel pain or discomfort in one or two extremities.

4. No Impairment:

Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.


Degree to which skin is exposed to moisture

1. Constantly Moist:

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist:

Skin is often but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist:

Skin is occasionally moist requiring an extra linen change approximately once a day.

4. Rarely Moist:

Skin is usually dry. Linen only requires changing at routine intervals.


Degree of physical activity

1. Bedfast:

Confined to bed.

2. Chairfast:

Ability to walk severely limited or nonexistent. Cannot bear own weight and/ or must be assisted into chair or wheelchair.

3. Walks Occasionally:

Walks occasionally during day but for very short distances with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently:

Walks outside the room at least twice a day and inside room at least once every two hours during waking hours.


Ability to change and control body position

1. Completely Immobile:

Does not make an even slight change in body or extremity position without assistance.

2. Very Limited:

Makes occasional slight changes in body or extremity position 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.


Usual food intake pattern

1. Very Poor:

Never eats a complete meal. Rarely eats more than one-third of any food offered. Eats two servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement:


Is NPO and/or maintained on clear liquids or IVs for more than five days.

2. Probably Inadequate:

Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement.


Receives less than optimum amount of liquid diet ...

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