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
15
ambulatory aid
none
bedrest
nurse assist
crutches, cane or walker
clutching onto furniture
30
intravenous therapy
20
gait
normal
wheelchair
weak
10
impaired
mental status
oriented to own capabilities
overestimates capabilities
forgets or unaware of limits
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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Specialty: Critical Care, Emergency Medicine, Pedatrics