Sensory perception
This subscale focuses on assessing a patient for:

• response to intense or prolonged pressure
• the ability of the patient to move, ask for help or express pressure related discomfort.

This is achieved by determining the patient’s cognition/level of consciousness. The levels are:

• Completely limited: comatose, no response to pain
• Very limited: unconscious, no response to verbal instruction
• Slightly limited: responds to verbal command, brief periods of eye opening, inconsistent ability to indicate pressure related discomfort. This subscale also focuses on cutaneous perception. This is divided into the same three levels:
• Completely limited: eg quadriplegia
• Very limited: e.g. hemiplegia or paraplegia
• Slightly limited: reduced sensory ability in 1 or 2 extremities, e.g. peripheral neuropathy, chronic neurological disease.

Mobility
This subscale focuses on assessing a patient’s ability and motivation to move and maintain a positional change. Do not take a turning regime into account here. Do consider the ability of the patient to make a slight change in their own position.
Three levels of assessment are used:

• Completely immobile: patient may make occasional, largely ineffectual movements for a few moments only but does not make a position change without assistance
• Very limited: sedated, depressed, or the patient who has a very strong preference for one particular position
• Slightly limited: needs help with major position changes and is able to make small, frequent moves by themselves.

Activity
This subscale focuses on assessing the degree of ambulation.
To determine the degree of ambulation, three assessment levels are used:

• Bed fast: patient cannot sit out of bed even once per day
• Chair fast: stand/walk a little, e.g. one to two steps for bed – chair transfer, brief period of standing, patient is either in bed or in a chair
• Walks occasionally: walking two or more times per day, e.g. patient with activity intolerance related to respiratory state or pain levels, walking to the shower and up for the toilet, but otherwise in a bed or chair.

Moisture
This subscale focuses on assessing the degree to which skin is exposed to moisture.
The four levels that are used are:

• Constantly moist: constant dribbling of urine, faecal oozing, and diaphoresis
• Often moist: dry for two to three hours between episodes of wetness, e.g. patient needs three changes of linen in 24 hours
• Occasionally moist: daily but infrequent wetness, e.g. incontinent nocte and maybe wet once during the day
• Rarely moist: dry for more than a day at a time.

Nutrition
This subscale focuses on assessing the patient’s usual dietary pattern.
The initial assessment may be based on the patient’s general nutritional appearance. The nurse should closely assess the patient’s usual dietary habits.

Friction
This subscale focuses on assessing the impact of shearing and friction forces upon the patient.
Three levels of assessment are used:

• Problem: poor clearance with transfers, unable to maintain a new position, significant posterior pelvic tilt, requires frequent repositioning/transfers using a hoist or slide sheets, bony prominences, high tone and extensor or flexor spasm
• Potential problem: requires some assistance with repositioning, fatigues with repeated transfers, kyphosis and mild posterior pelvic tilt
• No apparent problem: good postural alignment and good clearances with transfers.