Gosnell Scale for Predicting Risk of Pressure Ulcer

mental status

alert

Oriented to time, place and person. Responsive to all stimuli, and understands explanations.

1

apathetic

Lethargic, forgetful, drowsy, passive and dull. Sluggish, depressed. Able to obey simple commands. Possibly disoriented to time.

2

confused

Partial and/or intermittent disorientation to time, person and place. Purposeless response to stimuli. Restless, aggressive, irritable, anxious and may require tranquilizers or sedatives.

3

stuporous

Total disorientation. Does not respond to name, simple commands, or verbal stimuli.

4

unconscious

Non-responsive to painful stimuli.

5

continence

fully controlled

Total control of urine and feces.

1

usually controlled

Incontinence of urine and/or of feces not more often than once every 2 days. Or, has Foley catheter and is incontinent of feces.

2

minimally controlled

Incontinent of urine or feces at least once in 24 hours.

3

absence of control

Consistently incontinent of both urine and feces.

4

mobility

full

Able to control and move all extremities at will. May require the use of a device but turns, lifts, pulls, balances, and attains sitting position at will.

1

slightly limited

Able to control and move all extremities but a degree of limitation is present. Requires assistance of another person to turn, pull, balance and/or attain a sitting position at will but self-initiates movement or request for help to move.

2

very limited

Can assist another person who must initiate movement via turning, lifting, pulling, balancing and/or attaining a sitting position (contractures, paralysis may be present).

3

immobile

Does not assist self in any way to change position. Is unable to change position without assistance. Is completely dependent on others for movement.

4

activity

ambulatory

Is able to walk unassisted. Rises from bed unassisted. With the use of a device such as a cane or walker is able to ambulate without the assistance of another person.

1

walks with help

Able to ambulate with assistance of another person, braces or crutches. May have limitation of stairs.

2

chairfast

Ambulates only to chair, requires assistance to do so. Or, is a confined to a wheelchair.

3

bedfast

Is confined to bed during entire 24 hours of the day.

4

nutrition

regular food intake

Eats some food from each basic food category every day and the majority of each meal served. Or, is on tube feeding.

1

occasionally misses food intake

Occasionally refuses a meal or frequently leaves at least half of a meal.

2

seldom intakes food

Seldom eats a complete meal and only a few bites of food at a meal.

3