Morse Scale Flashcards
1
Q
History of falling; immediate or within three months
A
No: 0
Yes: 25
2
Q
Secondary diagnosis
A
No: 0
Yes: 15
3
Q
Ambulatory aid:
Bed rest/ nurse assist
Crutches can’t walker
Furniture
A
0
15
30
4
Q
IV/heparin lock
A
No: 0
Yes: 20
5
Q
Gait/transferring
Normal:”/bed rest/immobility
Weak impaired
A
0
10
20
6
Q
Mental status
Oriented to own ability
Forgets limitations
A
0
15
7
Q
No risk
A
0-24 good basic nursing care
8
Q
Low risk
A
25-50 implement standard fall prevention interventions
9
Q
High risk
A
_> 51 implement high risk fall prevention interventions
