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John Hopkins Fall Risk Assessment Tool

The document outlines the John Hopkins Fall Risk Assessment Scale used at Mar Sleeva College of Nursing Palai, detailing demographic information and various risk factors for falls. It includes a scoring system based on age, fall history, medication, patient care equipment, mobility, and cognition to categorize patients into no risk, moderate risk, or high risk. The assessment aims to identify patients at risk of falls to implement appropriate safety measures.

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Sonia Paul
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490 views3 pages

John Hopkins Fall Risk Assessment Tool

The document outlines the John Hopkins Fall Risk Assessment Scale used at Mar Sleeva College of Nursing Palai, detailing demographic information and various risk factors for falls. It includes a scoring system based on age, fall history, medication, patient care equipment, mobility, and cognition to categorize patients into no risk, moderate risk, or high risk. The assessment aims to identify patients at risk of falls to implement appropriate safety measures.

Uploaded by

Sonia Paul
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MAR SLEEVA COLLEGE OF NURSING PALAI

JOHN HOPKINS FALL RISK ASSESSMENT SCALE


Introduction

Demographic Details:

Name :

Age :

Sex :

Address :

I.P No :

Ward :

Room/Bed No :

Marital Status :

Education :

Occupation :

Religion :

Informant :

Date of admission :

Consultant Doctor :

Diagnosis :

Present Medical History

Past Medical History

Present Surgical History

Past Surgical History


Fall risk assessment
Date
Points M E
AGE* 60—69 yrs 1

70– 79 yrs 2

> 80 yrs 3

FALL One fall within 6 months before 5


HISTORY* admission
Examination incontinence 2
bowel
&bladder* Urgency or frequency 2

Urgency or frequency &incontinence 4

MEDICATIO On one high fall risk drug 3


N*
+ On 2 or more high fall risk drugs 5

Sedated procedures within past 24 7


hrs
PATIENT One present 1
CARE
EQUPMENT * Two present 2
++
Three or more present 3

MOBILITY ** Requires assistance or supervision 2


for mobility, transfer or ambulation
Unsteady Gait 2

Visual /auditory impairment 2


affecting mobility
Cognition Altered awareness of immediate 1
physical environment
Impulsive 2

Lack of understanding of ones 3


physical and cognitive limitations
TOTAL

NB: * Single select ** multiple select


+ includes PCA /opiates , anticonvulsants, anti-hypertensive,
diuretics, hypnotics, laxatives, sedatives and psychotropic
++ IV infusion, chest tube, indwelling catheters etc…

CATOGORY SCORE
No Risk Less than 6

Moderate 6-13

High risk More than 13

Conclusion

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