The Gosnell scale is used to assess the risk of pressure
sore development.
(1) mental
status: an assessment of one's level of response to his/her environment
•
interventions: all devices, measures and/or nursing care activity being used
for the purpose of pressure sore prevention
|
Parameter
|
Finding
|
Description
|
Points
|
|
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 incontent 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
|