fall precautions and restraints

Question 1

what is the scale to assess a patient’s likelihood of falling?

Answer 1

The Morse Fall Scale.

Question 2

how to determine the fall risk using the Morse Fall Scale?

Answer 2

1. if there is a history of falling within 3 months/ immediate: yes = 25, no = 0
2. a secondary diagnosis (medical diagnosis) : yes = 15, no = 0
3. if there is need for an aid:
   - bed rest/ nurse assist = 0
   - crutches/ cane/Walker = 15
   - furniture = 30
4. IV/ Heparin lock: yes = 20, no = 0
5. gait/ transferring:
   - normal/ bed rest/ immobile = 0
   - weak = 10
   - impaired = 20
6. mental status:
   - orientated to own ability = 0
   - forgets limitations: 15
   To determine fall risk:
   0-24 = no risk -> good basic nursing care
   25-50 = low risk -> implement standard fall precaution intervention
   more than or equal to 51 = high risk -> implement standard high fall precaution intervention

Question 3

types of physical restraints

Answer 3

• bed rails
• full body/ waist vest
• hand mittens
• seat belts/ chest boards
• limb restraints