Unit 2 - Fall Risk Assessment Tools

Question 1

What assessment tools are used for fall risks? (3)

Answer 1

• Hendrick II Fall Risk Model
• Falls Risk Assessment Tool
• Functional performance

Question 2

How many risk factors are assessed with the Hendrick II Fall Risk Assessment Model? (2)

Answer 2

• 8 risk factors assessed
• 5 or more means at risk

Question 3

What risk factors are assessed with the Hendrick II Fall Risk Assessment Model? (8)

Answer 3

1. Cognition
2. Symptomatic depression
3. Altered elimination
4. Dizziness or vertigo
5. Gender
6. Medications
7. Get up and go “rising from the chair”
   - 4 diff. components
8. Balance

Question 4

Hendrick’s Tool Chart

Answer 4

see more on page 61

Question 5

What is orthostatic blood pressure? (3)

Answer 5

• align to standing position
• if blood pressure drops too much
• some meds affect it

Question 6

How do you assess orthostatic blood pressure? (4)

Answer 6

1. Older adults in the supine position for greater than 5 minutes
2. Take blood pressure immediately after standing
3. Take blood pressure two minutes after standing
4. A drop of greater than 20 mmHg in systolic pressure immediately or 2 min after indicates orthostatic hypertension

Question 7

How do you treat orthostatic bp? (3)

Answer 7

• diagnosis and treat underlying cause
• medications?
• Hydrations?

Question 8

The Berg Balance Scale is also a performance based measure of fall risk. What does it assess? (7)

Answer 8

• balance on functional tasks
  1. Sitting to standing
  2. Standing unsupported
  3. Sitting with back unsupported but feel supported on the floor or in a chair
  4. Standing to sitting
  5. Transfers
  6. Standing unsupported with eyes closed

Question 9

is the minimum data set performance based?

Answer 9

• yes