Page 28 - CLINICAL PRACTICE II

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MOBILITY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO
Ability to IMMOBILE – Does Makes occasional LIMITED – Makes LIMITATIONS –
change and not make even slight slight changes in body frequent Makes major and
control body changes in body or or extremity position though slight changes frequent changes in
position extremity position but unable to make in body position without
without frequent or significant or extremity position assistance.
assistance. changes independently.
independently.

SENSORY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO IMPAIRMENT
PERCEPTION LIMITED – Responds only to LIMITED –Responds to – Responds to
Ability to Unresponsive painful stimuli. Cannot verbal commands but verbal commands.
respond (does not moan, communicate cannot always Has no sensory
meaningfully flinch, or discomfort except by discomfort or need to be deficit which would
to grasp) to painful moaning or turned OR has some limit ability to feel or
pressure- stimuli, restlessness OR has a sensory impairment voice pain or
related due to diminished limit the ability to feel which limits ability to discomfort?
discomfort level of pain or discomfort over feel pain or discomfort
consciousness or ½ of body. in 1 or 2 extremities.
sedation, OR limited
ability to feel pain
over most of body
surface.

MOISTURE 1. CONSTANTLY 2. OFTEN MOIST – 3. OCCASIONALLY 4. RARELY MOIST
Degree to MOIST– Skin is kept Skin is often but not MOIST – – Skin is usually dry;
which moist almost always moist. Linen Skin is occasionally linen only requires
skin is constantly by must be changed at moist, requiring an extra changing at routine
exposed to perspiration, urine, least once a shift. linen change intervals.
moisture etc. approximately once a
Dampness is day.
detected every time
patient is moved or
turned.

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