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Cheatography

Morse Fall Scale Cheat Sheet (DRAFT) by [deleted]

Fall Risk is based upon Fall Risk Factors

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction - Morse Fall Scale

Fall Risk is based upon Fall Risk Factors and it is more than a Total Score. Determine Fall Risk Factors and Target Interv­entions to Reduce Risks. Complete on admission, at change of condition, transfer to new unit, and after a fall.
Credit: SAGE Public­ations

Morse Fall Scal3

Variable
Rating
Score
Hisotry of Falling
No =0
Y=25
[____}
Secondary Diagnosis
No =0
Y=15
[____}
Ambulatory Aid
None/bed rest /nurse assist=0
Crutches/cane/ walker=15
[____}
IV or IV access
No =0
Y=20
[____}
Gai
Normal/bed rest/ wheelchair=o
Weak=10
[____}
Mental status
Knows own limits =0
Overestimates or forgets limit=15
[____}
 
Total
[____}

Sample Risk Level

Risk Level
MFS Score
Nursing Action
No Risk
1-24
Good Basic Nursing Care
Low Risk
25-50
Implement Standard Fall Prevention Interv­entions
High Risk
>50
Implement High Risk Fall Prevention Interv­entions
Important Note: The Morse Fall Scale should be calibrated for each particular healthcare setting or unit so that fall prevention strategies are targeted to those most at risk. In other words, risk cut off scores may be different depending on if you are using it in an acute care hospital, nursing home or rehabi­lit­ation facility. In addition, scales may be set differ­ently between particular units within a given facility.
 

Assessment

- Assess patient’s ability to comprehend and follow instru­ctions
- Assess patient’s knowledge for proper use of adaptive devices
- Need for side rails: up or down
- Hydration: monitor for orthos­tatic changes
- Review meds for potential fall risk (HCTZ, Ace inhibi­tors, Ca channel blockers, B blockers)
- Evaluate treatment for pain

Safety Factors

- Maintain bed in low position, bed alarm when needed
- Call bell, urinal and water within reach. Offer assistance with elimin­ation needs routinely
- Buddy system
- Wrist band identi­fic­ation
- Ambulate with assistance
- Do not leave unattended for transfers / toileting
- Encourage patient to wear non-skid slippers or own shoes
- Lock bed, wheelc­hairs, stretchers and commodes

Family­/Pa­tient Education

- PT consult for gait techniques
- OT for home safety evaluation
- Family involv­ement with confused patients - Sitters
- Instruct patien­t/f­amily to call for assistance with out-of-bed activities
- Exercise, nutrition
- Home safety (including plan for emergency fall notifi­cation procedure)

Enviro­nment

- Room close to nurses station
- Orient surrou­ndings, reinforce as needed
- Room clear of clutter
- Adequate lighting
- Consider the use of technology (non-skid floor mats, raised edge mattresses