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.
An 85-year-old with dementia fell yesterday evening. Secondary diagnosis: dementia. He wanders holding chair backs for support, has a saline lock, shuffling impaired gait, and attempts bathroom trips alone at night without calling.
Complete Morse scoring for nocturnal wandering with dementia.
History of Falling
Secondary Diagnosis
Ambulatory Aid
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