Clinical Documentation
Wounds -- Gosnell Scale
This assessment identifies individuals living in extended care and over the age of 65 at risk for developing pressure ulcers.
| MENTAL STATUS | Unconscious (1) -- nonresponsive to painful stimuli |
|---|---|
| Stuporous (2) -- total disorientation. Does not respond to name, simple commands or verbal stimuli. | |
| Confused (3) -- partial and/or intermittent disorientation to temperature, pulse and respiration. Purposeless response to stimuli. Restless, aggressive, irritable, anxious and may require tranquilizers or sedatives. | |
| Apathetic (4) -- lethargic, forgetful, drowsy, passive and dull, sluggish, and depressed. Able to obey simple commands. Possibly disoriented to time. | |
| Alert (5) -- oriented to time, place and person. Responsive to all stimuli and understands explanations. | |
| CONTI- NENCE |
Absence of control (1) -- incontinent of both urine and feces |
| Minimally controlled (2) -- often incontinent of urine with occasional to frequent incontinence of feces | |
| Usually controlled (3) -- incontinent of urine and/or feces once in a while, or has Foley catheter and is incontinent of feces | |
| Fully controlled (4) -- total control of urine and feces | |
| MOBILITY | Immobile (1) -- cannot change position without assistance. Is completely dependent on others for movement. |
| Very limited (2) -- with some assistance, can change position. May have contractures, paralyses, etc. | |
| Slightly limited (3) -- can control and move all extremities but with some limitations. Requires the assistance of another person to change position. | |
| Full (4) -- can control and move all extremities at will. May need a device, but can turn, lift, pull, balance and attain sitting position at will. | |
| ACTIVITY (ability to walk) |
Bedfast (1) -- is confined to bed during entire 24-hour day. |
| Chairfast (2) -- walks only to a chair; requires assistance to do so or is confined to a wheelchair. | |
| Walks with help (3) -- can walk with assistance of another person, braces, or crutches. May have limitation on stairs. May have unsteady gait. | |
| Ambulatory (4) -- can walk unassisted. Rises from bed unassisted. With a cane or walker, can ambulate without assistance. | |
| NUTRITION | Poor (1) -- seldom eats a complete meal; eats only a few bits of food a meal. Is dehydrated and has minimal fluid intake. |
| Fair (2) -- occasionally refuses a meal or frequently leaves the larger portion of a meal. Must be encouraged to take fluids. | |
| Good (3) -- eats some food from each category of the Basic Four every day. Drinks 6-8 glasses of fluid every day. Eats the major portion of each meal served or is receiving tube feedings. | |
| SKIN STATUS |
Skin appearance (description of observed skin characteristics): dry, oily, wrinkled, scaly, flaccid and so on. |
| Skin tone (degree of turgor and tension of the skin determined by pinch at specific high-risk sites for pressure sores): hard, moderate, loose. | |
| Skin sensation (response of an individual to tactile stimuli of the epidermis. Identified high-risk sites for pressure sores stimulated for touch and two-point discrimination): None, slight, moderate, great. | |
| Text field: enter notes describing skin (optional) | |
| SCORING | |
| The five scores are summed. The result is an indicator of risk for developing pressure ulcers. 5 is the worst prognosis. 20 is the best prognosis. Complete evaluation also includes recording of vital signs, skin condition and medications, but these are not scored. |