The document outlines fall risk assessment procedures primarily for older adults, including initial screening questions and specific tasks to evaluate strength, balance, and gait. It details various assessment tools such as the timed up-and-go test, 30-second chair stand test, and the 4-stage balance test, as well as the Morse Fall Scale (MFS) used to classify fall risk levels. The MFS provides scores for risk assessment and determines appropriate fall prevention interventions based on the patient's condition.

1. FALL RISK ASSESSMENT
Kuldeep Vyas
Associate Professor
Dept. Community Health Nursing

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FALL RISK ASSESSMENT
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 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.

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3. 4-Stage 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.

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The Morse Fall Scale (MFS)
Item Response
History of Falling immediate or within 3 months No = 0
Yes = 25
Secondary Diagnosis No = 0
Yes = 15
Ambulatory Aid None, Bed Rest, Wheel Chair, Nurse = 0 Crutches, Cane,
Walker = 15
Furniture = 30
IV/ Heparin Lock No = 0
Yes = 20
Gait/ Transferring Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
Mental status
Score and interpretation of the Morse Fall Scale (MFS)
Risk Factor MFS Score Action
No risk 0-24 None
Low risk 25-50 Initiate Standard fall prevention
interventions
High risk >51 Initiate High Risk fall prevention
interventions
Oriented to own ability = 0
Forgets limitations = 15

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Thank You…