1、 莫爾斯摔倒量表莫爾斯摔倒量表(改編已經(jīng)獲得授權(quán)，SAGE出版)莫爾斯摔倒量表 (MFS) 是用來(lái)評(píng)估病人摔倒可能性的快速和簡(jiǎn)單的方法，評(píng)估病人的可能性下降。大部分的護(hù)士 (約82.9%) 稱它為快速和容易使用的量表，并且有54%的護(hù)士估計(jì)可以用少于 3 分鐘的時(shí)間來(lái)評(píng)估病人。它是由六個(gè)簡(jiǎn)單而快速測(cè)量的變量組成，并且已被證明有預(yù)測(cè)可靠性。MFS 廣泛應(yīng)用于緊急護(hù)理場(chǎng)所，都是在醫(yī)院和長(zhǎng)期住院場(chǎng)所.項(xiàng)目評(píng)分得分1.摔倒的歷史; 3個(gè)月內(nèi)的否 0是 25 2.二次診斷否 0是 15 3. 動(dòng)態(tài)援助臥床休息護(hù)士協(xié)助拐杖/手杖/行走支具家具01530 4. 靜脈/肝素鎖否 0是 20 步態(tài)/轉(zhuǎn)移正常/臥

2、床/運(yùn)動(dòng)受限身體虛弱受損狀態(tài)010206.精神狀態(tài)自我評(píng)估忘記限制015表中的項(xiàng)按照以下規(guī)則進(jìn)行評(píng)分:摔倒的歷史: 如果病人在目前住院期間或者近期摔倒過(guò)，則得25分， 如果病人并沒(méi)有摔倒，則得0分。 注意: 如果病人第一次摔倒，那么他或她評(píng)分立即就會(huì)增加25。二次診斷: 如果病人的圖表上列出了多個(gè)醫(yī)療診斷那算是15分，如果不是，分?jǐn)?shù)為0。動(dòng)態(tài)援助: 如果病人能獨(dú)立行走、 使用輪椅，或臥床休息，并不離開(kāi)床，這得分為 0。如果病人使用拐杖、 手杖或行走支具，此項(xiàng)得分 15; 如果病人走動(dòng)還需要扶著旁邊的家具，分?jǐn)?shù)這一項(xiàng)目30。靜脈治療: 如果患者有靜脈的器具或肝素鎖插入才得分 20，如果不是，分?jǐn)?shù)

3、0。S.5 Morse fallS.5 Morse fallscale步態(tài):正常步態(tài)的特征是病人手臂自由擺動(dòng)的，走路時(shí)頭直立，不猶豫。這種步態(tài)，得 0 分。弱步態(tài)(10 分)：患者彎下腰，但能夠抬起頭走路而不會(huì)失去平衡。步驟很短，病人可能腳步拖沓。受損的步態(tài) (得分 20)：病人可能有難度從椅子上站起來(lái)，手按在椅子的扶手上 ，通過(guò)幾次嘗試站起。病人的頭部是下垂的，眼看地面。因?yàn)椴∪说钠胶饽芰苋?，病人可能扶著到家具，其他等，沒(méi)有外界支援不能走路的。精神狀態(tài): 當(dāng)使用這種量表時(shí)，要對(duì)病人的心理狀態(tài)進(jìn)行測(cè)量?？梢詥?wèn)病人，你能單獨(dú)去洗手間嗎？或您需要幫助嗎? 如果病人的回答和他或她的實(shí)際能力相符合，

4、病人被評(píng)為正常，得分為 0。 如果病人的反應(yīng)不符合護(hù)理常規(guī)或病人的反應(yīng)是不現(xiàn)實(shí)的，則認(rèn)為病人高估他或她自己能力和忘記自身的限制， 得分為15。風(fēng)險(xiǎn)水平和計(jì)分: 分?jǐn)?shù)記錄在病人的圖表上。然后據(jù)此確定風(fēng)險(xiǎn)水平和建議采取的行動(dòng) (例如不需要干預(yù)，標(biāo)準(zhǔn)摔倒預(yù)防干預(yù)措施，高風(fēng)險(xiǎn)預(yù)防干預(yù)措施) 。重要說(shuō)明: 這樣莫爾斯跌倒量表應(yīng)為每個(gè)特定醫(yī)療設(shè)置或單位進(jìn)行適應(yīng)性校準(zhǔn)。換句話說(shuō)，切斷分?jǐn)?shù)的風(fēng)險(xiǎn)可能取決于它的使用場(chǎng)所，例如急性護(hù)理醫(yī)院，療養(yǎng)院，康復(fù)設(shè)施。另外，評(píng)分也會(huì)因人而異。樣本風(fēng)險(xiǎn)水平風(fēng)險(xiǎn)水平MFS評(píng)分行動(dòng)沒(méi)有風(fēng)險(xiǎn)0 -24良好的基本護(hù)理照顧低風(fēng)險(xiǎn)25-50執(zhí)行標(biāo)準(zhǔn)摔倒預(yù)防干預(yù)措施高風(fēng)險(xiǎn)51執(zhí)行高風(fēng)險(xiǎn)摔倒

5、預(yù)防干預(yù)措施Morse FallScale(Adapted with permission, SAGEPublications)The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patients likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to r

6、ate a patient. It consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care settings,bothinthehospitalandlongtermcareinpatientsettings.ItemScaleScoring1. History of falling; immediate

7、 or within 3monthsNo0Yes25 2. SecondarydiagnosisNo0Yes15 3. AmbulatoryaidBed rest/nurse assist Crutches/cane/walker Furniture01530 4. IV/HeparinLockNo0Yes20 5. Gait/Transferring Normal/bedrest/immobile WeakImpaired010206. MentalstatusOriented to own ability Forgetslimitations015The items in the scal

8、e are scored asfollows:History of falling: This is scored as 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen, this is scored 0.

9、Note: If a patient falls for the first time, then his or her score immediately increases by25.Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed on the patients chart; if not, score0.Ambulatory aids: This is scored as 0 if the patient walks without a walking aid (

10、even if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not get out of bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the patient ambulates clutching onto the furniture for support, score this item30.Intravenous therapy: This is scored as

11、 20 if the patient has an intravenous apparatus or a heparin lock inserted; if not, score0.Gait: A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the patient is

12、stooped but is able to lift the head while walking without losing balance. Steps are short and the patient may shuffle. With an impaired gait (score 20), the patient may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using sev

13、eral attempts to rise). The patients head is down, and he or she watches the ground. Because the patients balance is poor, the patient grasps onto the furniture, a support person, or a walking aid for support and cannot walk without thisassistance.Mental status: When using this Scale, mental status

14、is measured by checking the patients own self- assessment of his or her own ability to ambulate. Ask the patient, “Are you able to go the bathroom alone or do you need assistance?” If the patients reply judging his or her own ability is consistent with the ambulatory order on the Kardex, the patient

15、 is rated as “normal” and scored 0. If the patients response is not consistent with the nursing orders or if the patients response is unrealistic, then the patient is consideredtooverestimatehisorherownabilitiesandtobeforgetfuloflimitationsandscoredas15.Scoring and Risk Level: The score is then tall

16、ied and recorded on the patients chart. Risk level and recommended actions (e.g. no interventions needed, standard fall prevention interventions, high risk prevention interventions) are thenidentified.Important Note: The Morse Fall Scale should be calibrated for each particular healthcare setting or unit so that fall prevention strategies are targeted to those most at risk. In other words, risk cut off scores may be different depending on if you are using it in an acute care hospital, nursing home or rehabilitation facility.Inadd