• 1. Completely Limited
  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
• 2. Very Limited
  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 the body
• 3. Slightly Limited
  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 externalities
• 4. No Impairment
  Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

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• 1. Constantly Moist
  Skin is kept moist almost constantly by perspiration, urine, etc. Dampness 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.

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• 1. Bedfast
  Confined to bed.
• 2. Chairfast
  Ability to walk severely limited or non-existent. 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 room at least twice a day and inside room at least once every two hours during walking hours.

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• 1. Completely Immobile
  Does not make even slight changes 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 Limitation
  Makes major and frequent changes in position.

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• 1. Very Poor
  Never eats a complete meal. Rarely eats more than ⅓ of any food offered. Eats 2 servings or less or 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.
• 2. Probably Inadequate
  Rarely eats a complete meal and generally eats only about ½ 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 or tube feeding.
• 3. Adequate
  Eats over half of most meals. Eats a total of 4 servings of protein (meet or 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.
• 4. Excellent
  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.

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• 1. Problem
  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. Potential Problem
  Moves feebly or requires minimum assistance. During a move skin pobably 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.
• 3. No Apparent Problem
  Moves in bed and in chair independently and has sufficient muscle strength to lift up.

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