Scribd
Upload
144 views12 pages

Fall Risk Assessment

The document outlines a fall risk assessment process primarily for older adults, which includes an initial screening and various assessment tools to evaluate strength, balance, and gait. Key components of the assessment are questions about past falls and tests such as the Timed Up-and-Go and Chair Stand Test. The Morse Fall Scale is also mentioned as a widely used tool for assessing fall risk in acute care settings.

Uploaded by

Roja V
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
144 views12 pages

Fall Risk Assessment

The document outlines a fall risk assessment process primarily for older adults, which includes an initial screening and various assessment tools to evaluate strength, balance, and gait. Key components of the assessment are questions about past falls and tests such as the Timed Up-and-Go and Chair Stand Test. The Morse Fall Scale is also mentioned as a widely used tool for assessing fall risk in acute care settings.

Uploaded by

Roja V
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

FA L L R I S K

AS S E S S M E N T
SUBMITTED BY ;
ROJA
R
ASSISTANT LECTURE
FALL RISK SSESSMENT
A fall risk assessment is used to find out
whether patient have a low, moderate, or
high risk falling. It is mostly done for older
adults.
The assessment usually
includes: -
1. An initial screening: - This includes a series of questions about overall
health and previous falls history or problems with balance, standing,
and/or walking.

2. A set of tasks, known as fall assessment tools: - These tools tests


strength, balance, and gait (Walking Style) of the patient .
Initial screening questions
are: -
1. Have you fallen in the past year?

2. Do you feel unsteady when standing or walking?

3. Are you worried about falling?


Fall assessment tools are:-

1. Timed Up-and-Go (Tug): - This test checks patient gait (Walking Style). Patient will
start in a chair, stand up, and then walk for about10 feetat regular pace. Then he will
sit down again, Health care provider will check how long it takes to do this. If it takes
12 seconds or more, it may mean at higher risk for a fall 2. 30-Second.

2. Chair Stand Test: - This test checks strength and balance. Patient will sit in a chair
with arms crossed over his chest. When provider says "go." he will stand up and sit
down again. Patient will repeat this for 30 seconds. Provider will count how many
times he can do this. A lower number may mean at higher risk for a fall. The specific
number that indicates a risk depends on age.
4 Stages Balance Test: -
This test checks how well patient can keep his balance. Patient will stand in
four different positions, holding each one for 10 seconds. The positions will
get harder as he goes,

 Position – 1 - Stand with feet side-by-side.


 Position - 2 - Move one foot halfway forward, so the instep is touching
the big toe of other foot
 Position – 3 - Move one foot fully in front of the other, so the toes are
touching the heel of other foot.
 Position – 4 - Stand on one foot If patient can't hold position 2 or
position 3 for 10 seconds or he can't stand on one leg for 5 seconds, it
may mean at higher risk for a fall
Fall assessment scale: -

The Morse Fall Scale (MFS) is a brief fall risk assessment tool
used widely in acute care settings. The MFS assesses a patient's
fall risk upon admission, following a change in status and at
discharge or transfer to a new setting. Prevention interventions
are based on the Morse Fall Scale score.

You might also like