Score fall-risk factors on the Morse Fall Scale — history of falling, secondary diagnosis, ambulatory aids, IV, gait, and mental status. Total points guide fall precautions.
Fundamental concept
Scoring fall history, secondary diagnoses, ambulation aids, IV therapy, gait, and mental status to target fall precautions.
After a large stroke the patient is bedbound with a heparin lock, no falls in the last year, secondary diagnosis of CVA, does not ambulate, gait scored as immobile, and is oriented but impulsive when transferring with one-person assist.
Apply Morse Fall Scale to a non-ambulatory stroke patient.
History of Falling
Secondary Diagnosis
Ambulatory Aid
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