Description

Morse et al developed a scale which can help to identify a patient at risk for falling.

A patient at increased should be targeted for preventive measures. The authors are from the University of Alberta in Canada.


Patient selection: patient >= 18 years of age

 

Parameters:

(1) history of falls

(2) secondary diagnosis

(3) ambulatory aid

(4) intravenous therapy or heparin lock

(5) gait

(6) mental status

 

Parameter

Finding

Points

history of falls

no

0

 

yes

25

secondary diagnosis

no

0

 

yes

15

ambulatory aid

none

0

 

bedrest

0

 

nurse assist

0

 

crutches, cane or walker

15

 

clutching onto furniture

30

intravenous therapy

no

0

 

yes

20

gait

normal

0

 

bedrest

0

 

wheelchair

0

 

weak

10

 

impaired

20

mental status

oriented to own capabilities

0

 

overestimates capabilities

15

 

forgets or unaware of limits

15

 

total score =

= SUM(points for all 6 parameters)

 

Interpretation:

• minimum score: 0

• maximum score: 125

• The higher the score the greater the risk of falling.

• Schwendimann et al identified a score >= 55 as high risk.


 


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