State steps for a fall assessment on a patient using the Morse Assessment fall Risk tool.

To conduct a fall assessment using the Morse Fall Scale, follow these steps:Here are the guidelines in using the Morse Fall Scale for a fall assessment:

 Steps for Morse Fall Scale Assessment:How to perform Morse Fall Scale Assessment as follows;

 Gather Patient Information:

 Hence, the following details should be gotten from the patient; the medical history, the current medications and the history of falls.

 Assess the Patient’s History:

 Fall History: Gemmell & Browne: “Has the patient fallen in the last three months?”

 Secondary Diagnosis: This may include any other factors that may increase the risk of the client to fall as follows:

 Perform the Physical Assessment:

 Ambulatory Aids: If the patient has any disability in the activities of daily living, if the patient is using any walking aid such as cane or walker.

 IV Therapy: It is also vital to check if the patient is on intravenous line or any other device as this increase the rates of fall.

 Gait and Mobility: Observe the patient’s mobility, whether the patient is independent in his/her movement or not, whether the patient can walk or not.

 Assign Scores Based on the Morse Fall Scale Criteria:Morse Fall Scale Criteria: Assign Scores as Follows:

 Fall History: The outcome measures were, for no fall, the participants will score zero, for one or two falls the participants will score 25 points, and for three or more falls the participants will score 50 points.

 Secondary Diagnosis: None (no secondary diagnosis): 0, Secondary diagnosis only: 15 points.

 Ambulatory Aids: None, 15 points for (cane or walker), 30 points for (crutches).

 IV Therapy: The above will be scored as follows; no administration of IV therapy 0 points, administration of IV therapy 20 points.

 Gait and Mobility: 0 points for normal; 10 points for mildly diminished; 20 points for diminished.

 Calculate the Total Score:

 The total points from each of the criteria to produce the total Morse Fall Scale score is illustrated below:

 Interpret the Score:

 Low Risk: Thus the maximum total score that a candidate can get is 24.

 Moderate Risk: For the age group of 25-44 the total score is:

 High Risk: A total score of is > 45

 Develop a Care Plan:

 Create a care plan that is commensurate with the level of risk and which takes account of the problem of falls. This may include interventions such as:This may includes measures like:

 Some of the environmental changes for instance include; having objects such as cords on the floor taken away.

 Teaching the patient the actions to be taken to avoid falling.

 Assistive devices and Supports: Use of the devices in the right manner

 Assessment and screening of the patient’s risk of falling should be done on regular basis

 Document the Assessment:

 The score of the Morse Fall Scale should be documented in the patient’s chart and the reason why the patient is assigned a particular risk level should also be documented. State the care plan and state all the actions that have been made in the process of the care.

 Review and Reassess Regularly:

 Perform a fall risk assessment of the patient periodically especially when there is a change in the patient’s status or when there is a change in the patient’s management plan