Fall Risk Exercise
Mr. P., 45-years-old, is admitted to your unit with the diagnosis severe abdominal pain with vomiting, and
diarrhea for three days. He is alert and oriented and able to walk to the bathroom without difficulty.
Instructions: Using the assessment screen below, circle the number in points the points column and then total
determine Mr. P’s fall risk.
Patient is disoriented to time, place, and/or person. Patient is unable to retain or
receive instructions or displays impaired judgment. This may be a progressive
neurological state, drug induced, or behavioral in origin. Stroke patients (left hemi) may
exhibit impulsive, unpredictable behavior as a result of the cerebral insult.
Medical diagnosis or nursing assessment finds the patient appears depressed, is not
interacting appropriately, is tearful, withdrawn, or the patient states they are
depressed. If the depression is managed with drugs and/or therapies in need NOT be
scored if the depression is therapeutically in control.
Altered elimination from the clinical norm, such as incontinence, nocturia, frequency,
urgency or stress incontinence, diarrhea, or related to use of cathartics. This does NOT
include a Foley or indwelling catheter UNLESS it causes symptoms referenced above
while in use with the patient. When the catheter is removed, it can be a high-risk time
until normal elimination is established.
Medical diagnosis of vertigo or the patient reports they feel like they are spinning or the
room is spinning. Sway path may be present when the patient stands (circular motion
upon arising). This is often seen in the aging adult with poor gait and balance and can
occur as a result of some drug side effects.
Carbamazepine, Divalproex Sodium, Ethotoin, Ethosuximide, Felbamate,
Fosphenytoin,Gabapentin, Lamotrigine, Mephenytoin, Methsuximide, Phenobarbitol,
Phenytoin, Primidone, Topiramate, Trimethadione, Valproic Acid
Alprazolam, Buspirone, Chlordiazepoxide, Clonazepam, Clorazepate Dipotassium,
Diazepam, Flurazepam, Halazepam, Lorazepam, Midazolam, Oxazepam,
Total Risk Score: ___________
Fall risk score 5 or greater: High Fall Ri
Fall risk score 10 or greater: Very High Fall risk
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