Monitor & Alert System

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Test it to know whether you or your loved one has high risk of fall...

The items in the scale are scored as follows:

History of falling:  25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls. If the patient has not fallen, this is scored 0.

* Note: If a patient falls for the first time, then his or her score immediately increases by 25.

Secondary diagnosis: 15 if more than one medical diagnosis is listed on the patient’s chart; if not, score 0.

Ambulatory aids:  0 if the patient walks without a walking aid (even if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture for support, score this item 30.

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

Gait: Score 0 for normal such as (walking with head erect, arms swinging freely at the side, and striding without hesitant). With a weak gait (score as 10), the patient is stooped but is able to lift the head while walking without losing balance. 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: 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.

Sample Risk Level