Nursing Admission Assessment
Comprehensive nursing assessment on IPD admission
Patient Identification
Vital Signs on Admission
Allergy Assessment
Morse Fall Risk Scale
| Risk Item | Score 0 | Score 25+ | Score |
|---|---|---|---|
| History of falling | No (0) | Yes (25) | |
| Secondary diagnosis (≥ 2 medical diagnoses) | No (0) | Yes (15) | |
| Ambulatory aid | None / Bed rest (0) | Crutch / Cane / Walker (15) / Furniture (30) | |
| IV / Heparin lock | No (0) | Yes (20) | |
| Gait | Normal / Bed rest / Immobile (0) | Weak (10) / Impaired (20) | |
| Mental status | Oriented to own ability (0) | Forgets limitations (15) |
Total Morse Score:40Moderate Fall Risk
Braden Pressure Ulcer Risk
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear
Score ≤ 18 = at risk for pressure injury