Think about the information provided in the case study then drag and drop the Activities of Daily Living (ADLs) you anticipate that Ms. Finney (RF) will be able to perform independently, and which activities will require additional assistance
eating
grooming
bathing
mouthcare
dressing
toileting
managing money
grocery shopping
cooking
house cleaning
laundry
taking medications
using the telephone
accessing transportation
Basic versus Instrumental ADL Drag and Drop. Based on the ADL the image is depicting drag the image into either the Basic ADL or Instrumental ADL column
Fill in the Morse Fall Scale numeric score for each item below based on the information in the case study. If you cannot answer an item question due to missing data enter a zero. After you have entered a score for all 6 items, add up the the total score and answer the remaining questions.
1. History of falling (immediate or previous): No=0 Yes=25
2. Secondary diagnosis (≥ 2 medical diagnoses in chart): No=0 Yes=15
3. Ambulatory aid: None/bedrest/nurse assist=0 Crutches/cane/walker=15. Use of furniture for support while ambulating=30
4. Intravenous therapy/heparin lock: No=0 Yes=20
5. Gait: Normal/bedrest/wheelchair=0 Weak=10 Impaired=20
6. Mental status: Oriented to own ability=0 Overestimates/forgets limitations=15
Based on the information in the case study, which of the following is the best Morse Fall Score for Ms. Finney?
- less than 25: Low Risk
- 25-45: Moderate Risk
- Greater than 45: High Risk
Which of the following data points from the case study were pertinent to Ms. Finney's Morse Fall score? Select all that apply.
- Slightly hard of hearing both ears
- currently uses no assistive devices
- Lives alone in a single home
- ovarian cancer
- Alert, well-groomed, well-spoken, fiercely independent
- laundry facilities and garage on basement level
- hypothyroidism
Which of the following assesments would you need so that you could more completely calculate Ms. Finney's fall risk using the Morse Fall Scale? Select all that apply.
- Inspect for intravenous access device
- Assess vision and hearing
- Inspect medications for sedatives and narcotics
- Assess muscle strength in lower extremities using Lovett Scale
- "Do you support yourself on furniture when you are walking around"
- Observe gait and posture
- "Have you ever fallen?"