Morse fall Scale (MFS), scale scoring fall for adult patients

The assessment of the risk of Falling is an assessment of the factors – factors that may cause the patient to fall. Fall itself is an event reported by sufferers or eye witnesses who saw the incident, i.e. someone suddenly lies/sitting on the floor/lower place with or without loss of consciousness or wound.

One of the methods used to assess the risk of patient falls is the Morse falls scale (MFS), Morse scale commonly used for adult patients. The scale of the fall in Morse is a method that is quick and easy to use. Using this method a nurse will take less than three minutes to assess the risk of falling of a patient.

Morse fall scale has six variables that can be used quickly to be able to assess the risk of falling. The MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings.

The items in the scale are scored as follows:

A history of falling : if new patient enter the hospital then fall or have a history of falls in the previous physiological like seizures, or other distractions. And score is 0 if the patient does not fall. Note : If patient falls for the first time score is 25

Secondary diagnosis : if the patient has two medical diagnose score is 15, if not given score 0. Tools : Given the score 0 if patien does not use walking AIDS including assisted nurse, using a wheel chair or not out of room at all score is 15, if using tools such as a cane cruthes or another walking AIDS. And score 30 if patients if the patient ambulated clutching onto the furniture for support.

Intravenous therapy: This is scored as 20 if the patient has an intravenous apparatus or a heparin lock inserted; if not, score 0.

Gait: A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the patient is stooped but is able to lift the head while walking without losing balance. Steps are short and the patient may shuffle. With an impaired gait (score 20), the patient may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using several attempts to rise). The patient’s head is down, and he or she watches the ground. Because the patient’s balance is poor, the patient grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance.

Mental status: When using this Scale, mental status is measured by checking the patient’s own self assessment of his or her own ability to ambulate. Ask the patient, “Are you able to go the bathroom alone or do you need assistance?” If the patient’s reply judging his or her own ability is consistent with the ambulatory order on the Kardex®, the patient is rated as “normal” and scored 0. If the patient’s response is not consistent with the nursing orders or if the patient’s response is unrealistic, then the patient is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15.

Scoring and Risk Level: The score is then tallied and recorded on the patient’s chart. Risk level and recommended actions (e.g. no interventions needed, standard fall prevention interventions, high risk prevention interventions) are then identified.

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.

Sample Risk Level.

Classification of actions that can be performed against a nurse the patient in accordance with a score of scoring.

a. Low risk.
  • Make sure the doorbell is easy to reach by the patient.
  • The wheels locked in a State berth.
  • Position the bed at the lowest position.
  • A Safety Railing of the bed is raised.
b. high risk
  • Do all the preventive guidelines for low-risk
  • Attach a special Bracelet (yellow color) as a sign of a patient's risk of falling.
  • Place the sign patient risk falls on the list the name of the patient (yellow)
  • Give the sign patient risk falls on the patient's door
  • Visit and monitor patients every one hour
  • Place the patient in bed closest to the nurse station (if possible)
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