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Morse Falls Pocket Card PDF

The Morse Fall Scale is used to assess a patient's fall risk based on factors such as history of falling, need for assistance with ambulation, and mental status. It provides a total score that guides interventions to reduce risks, such as keeping beds in low positions, using bed alarms, and having patients wear non-skid slippers. Safety factors, assessments, education, and environmental considerations are also important to address to help prevent falls.

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667 views2 pages

Morse Falls Pocket Card PDF

The Morse Fall Scale is used to assess a patient's fall risk based on factors such as history of falling, need for assistance with ambulation, and mental status. It provides a total score that guides interventions to reduce risks, such as keeping beds in low positions, using bed alarms, and having patients wear non-skid slippers. Safety factors, assessments, education, and environmental considerations are also important to address to help prevent falls.

Uploaded by

Amadea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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.

Variables Score
History of no 0
Falling yes 25 ______

Secondary no 0
Diagnosis yes 15 ______

Ambulatory None/bed rest


Aid /nurse assist 0
Crutches/cane/
walker 15 ______
Furniture 30
IV or IV no 0
access yes 20 ______
Gait Normal/bed rest/
wheelchair 0
Weak 10 ______
Impaired 20
Mental Knows own limits 0
status Overestimates or ______
forgets limits 15

Total ______
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
Assessment
- Assess patients ability to comprehend and follow
instructions
- Assess patients 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
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)

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