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    Frass

    Uploaded by

    Mohammed
    This tool aims to assess patients' risk of falling using several risk factors. Nurses evaluate patients on factors like age, mental status, toileting needs, history of falls, medications, and more. Scores are totaled to determine a patient's risk level as high or super high. For high risk patients, fall prevention strategies are implemented like optimizing mobility, ensuring call buttons are accessible, addressing incontinence or vision issues, and reinforcing functional limitations.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Frass

    Uploaded by

    Mohammed
    40 views2 pages
    This tool aims to assess patients' risk of falling using several risk factors. Nurses evaluate patients on factors like age, mental status, toileting needs, history of falls, medications, and more. Scores are totaled to determine a patient's risk level as high or super high. For high risk patients, fall prevention strategies are implemented like optimizing mobility, ensuring call buttons are accessible, addressing incontinence or vision issues, and reinforcing functional limitations.

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    This tool aims to assess patients' risk of falling using several risk factors. Nurses evaluate patients on factors like age, mental status, toileting needs, history of falls, medications, and more. Scores are totaled to determine a patient's risk level as high or super high. For high risk patients, fall prevention strategies are implemented like optimizing mobility, ensuring call buttons are accessible, addressing incontinence or vision issues, and reinforcing functional limitations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    40 views2 pages

    Frass

    Uploaded by

    Mohammed
    This tool aims to assess patients' risk of falling using several risk factors. Nurses evaluate patients on factors like age, mental status, toileting needs, history of falls, medications, and more. Scores are totaled to determine a patient's risk level as high or super high. For high risk patients, fall prevention strategies are implemented like optimizing mobility, ensuring call buttons are accessible, addressing incontinence or vision issues, and reinforcing functional limitations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    FRASS

    T. 06a
    This tool aims to identify patients at high risk of falling.
    Name:
    Instructions:
    UR/MR number:
    Assess patient’s current status for each risk factor and record the relevant
    Ward/Unit:
    rating in the scoring system. Add up total scores and record in space provided.
    DOB: Gender:
    Admission Date:
    COMPLETED BY: Place UR sticker here or add patient details:

    DATE:

    Risk Factor Rating / / 04 / / 04 / / 04


    Score Score Score

    AGE
    65 – 79 years (1)
    80 and above (2)

    MENTAL STATUS
    Oriented at all times or Comatose (0)
    Confused at all times – poor cognition, STM, lack of insight into own safety, (4)
    impulsive
    Intermittent confusion – as above (8)

    EMOTIONAL STATUS
    Moderately agitated/uncooperative/anxious (2)
    Severely agitated/uncooperative/anxious (4)

    TOILETING
    Independent and continent (0)
    Catheter &/or ostomy (1)
    Needs assistance with toileting (3)
    Ambulatory with urge incontinence or episodes of incontinence (5)

    HISTORY OF FALLING WITHIN 6 MONTHS


    No (0)
    Has fallen one or two times (2)
    Multiple history of falling (5)

    SENSORY IMPAIRMENT
    Blind/Deaf/Cataracts/Not using corrective device (1)

    ACTIVITY
    Ambulates/Transfers without assistance (0)
    Ambulates/Transfers with assist of one or assistive device (2)
    Ambulates/Transfers with assist of two (1)
    Unsteady gait/mobility affected by pain/deconditioned (2)

    MEDICATIONS (MEDICATION REFERENCE TABLE OVER PAGE)


    Cardiovascular/Antihypertensives Anti depressants
    Psychotropics Tranquillisers/Sedatives
    Anti-parkinsons/Anti-Convulsives Opiods Diuretics
    None of the above listed medications (0)
    One of the above listed medication (1)
    Two or more of the above listed medications (2)
    Add one more point if there has been a change in these medications or (1)
    dosages in the past five days.

    TOTAL SCORE
    Level of Risk: Score of 8 - 14 patient is at high risk for falls
    Score of 15 + patient is at SUPER HIGH risk for falls
    Document each patients falls risk status in the medical history. Implement appropriate
    fall prevention strategies (overpage)
    FRASS FALLS PREVENTATIVE STRATEGIES
    T. 06b
    RISK FACTOR GOAL INTERVENTIONS

    IMPAIRED ACTIVITY Optimise mobility Refer for physiotherapy assessment


    OVER ACTIVITY (Ensure safe walking) Review footwear needs
    Keep walking aids within easy reach
    WANDERER
    Ensure appropriate seating
    DECONDITIONED Document transfer/mobilisation assistance

    MENTAL STATUS Promote feeling of security Bed placed in lowest position with
    (Re-orientation) brakes applied
    Talk slowly and clearly
    Minimise number of bed location movements
    Encourage family members to sit with patient
    Encourage optimal hydration/nutrition

    IMPAIRED VISION Promote uncluttered environment Remove clutter & obstacles from room
    (Prevent accidents) Orientate patient to environment
    Ensure adequate night lighting in toilet
    and room
    Wear spectacles as appropriate

    INFLUENCE OF MEDICATIONS Provide safe Environment Liaise with Pharmacy/medical staff


    (Prevent accidents) Implement strategies to reduce effects of
    postural hypotension
    Influence of opioids/sedatives

    Nurse call button handy


    INCONTINENCE/URINARY BOWEL
    Bladder Bowel Pattern Establish toileting regime, toilet before
    URGENCY
    (Anticipate needs) settling
    Commode by bed, urinal handy

    MISPERCEPTION OF FUNCTIONAL Reinforce limitations Do not leave alone in bathroom/toilet


    ABILITIES (Anticipate needs) Assist/supervise all activities

    ALWAYS ENSURE:
    Call bell is handy Remove clutter Adequate night lighting

    PATIENTS AT HIGH RISK OF FALLS MUST HAVE COLOURED WRIST BAND AND CHART OR RISK FLAGGED

    MEDICATION REFERENCE TABLE

    CARDIOVASCULAR/ NEUROLEPTICS OPIOIDS


    ANTI-HYPERTENSIVES Chlorpromazine Morphine
    Captopril Clozapine MS Contin
    Enalapril Pericyazine Endone
    Sotalol Thioridazine Tramadol
    Ca channel blocker All others Panadeine Forte
    ACE Inhibitors Oxycontin
    GTN (oral, SL, patch) TRANQUILLISERS/SEDATIVES
    Angiotensin II antagonists DIURETICS
    Diazepam
    B blockers Fusemide
    Benzodiazepams
    Prazosin
    Clonazepam Thiazides
    Nitrazepam Amiloride - Moduretic
    ANTI-DEPRESSANTS Oxazepam
    Amitriptyline OTHERS
    Dothiepin ANTI-PARKINSON/ANTI-CONVULSIVES Baclofen
    Imipramine
    Benztropine Ditropan
    Mianserin
    Bromocriptine Statins
    SSRI
    Levodopa NSAIDS
    Doxepin
    Lamotigine Laxatives
    Carbamazepine

    A more extensive list of medications associated with increased falls risk is provided separately in the Tools Supplement (Minimising the risk of falls and
    fall-related injuries: Guidelines for acute, sub-acute and residential care settings).

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