ABCs of Injury Risk Identification - Identification are at most risk for injury if they sustain a fall.
A = Age - Individuals who are at least or > 85 years old and/ or frail due to clinical condition.
B = Bones - Patients with bone conditions, including osteoporosis, a previous fracture, prolonged steroid use of metastatic bone cancer.
C = Coagulation - Patients with bleeding disorders, either through use of anticoagulants or an underlying clinical condition.
s = Surgery - Post-surgical patients, especially patients who have had a recent lower limb amputation or recent major abdominal or thoracic surgery. Morse Fall Scale 1. History of falling; immediate or within 3 months No - 0 Yes - 25 2. Secondary Diagnosis No - 0 Yes – 15 3. Ambulatory Aid Bed rest/ nurse assist - 0 Crutches/ cane/ walker - 15 Furniture – 30 4. Intravenous therapy/ Intravenous Access No - 0 Yes – 20 5. Gait/ Transferring Normal/ bed rest/ immobile - 0 Weak - 10 Impaired – 20 6. Mental Status Orientated to own ability - 0 Overestimates/ Forgets limitations (cognitive impairment) - 15 Risk Level: Low - 0-44 High - > 44 – Implement High Fall Risk Interventions Fall & Injury Reduction Interventions Universal Fall Precautions – to be used with ALL patients regardless of age, diagnosis, etc.
