Thursday, 28 February 2019

Risk Fall Assessment in Patients with the Morse Scale

Risk Fall Assessment in Patients with the Morse Scale

Patient safety is the patient's right. The patient has the right to obtain security and safety during the period of care at the hospital (Ministry of Health, 2009).

Patients who are hospitalized have the right to get safe care through a system that can prevent unexpected events or KTD. Herefore the implementation of the patient safety program must be implemented properly. From the data obtained that since the adoption of SPO identification of patients at risk of falls found in January-March 2010 there were 3 patients who fell.

The purpose of this study is to identify the implementation of the Standard Operating Procedure for Identifying the Risk of Patients Falling Using a Scale of Morse Fall in "A" Hospital Bandung. Design research using quantitative descriptive with data sourced from room nurses. The instrument of this study uses observation when receiving new patients every day.

Conclusions from the study of the Implementation of Standard Operating Procedure: Identification of the Risk of Patients Falling Using the Scale of Morse Fall In "A" Hospital Bandung is 66.48% with good criteria, 8.11% with sufficient criteria and 25.41% with less criteria. Recommendations in this study improve the ability of nurses to categorize patients based on falling morse scale and do good documentation so that nursing care becomes comprehensive.

It was reported that patients fell in hospitals in Indonesia from January to September 2012 by 14% (Persi Congress XXI, 2012). Falling will result in various types of injuries, physical damage and even psychological damage.  Every patient in the inpatient room has a risk of falling, therefore the role of a nurse is very important in preventing the incidence of risk falling in patients.

Risk Fall Assessment in Patients with the Morse Scale

Pay attention, patients with one of the following things have an increased risk of falling.

• Agitation / delirium: infection, toxic / metabolic, cardiopulmonary changes, CNS, dehydration / blood loss, sleep disorders.
 • Drugs (dose / time): psychotropic drugs, cardiovascular drugs (especially digoxin), anticoagulants (increasing the risk of injury), anticholinergics, preparations for the large intestine • Orthostatic hypotension, autonomic failure
• Often to the bathroom
 • Mobility is interrupted
• Impaired vision, inappropriate use of tools / footwear
• History of falls (cardiovascular / dizziness / staggering, loss of balance without movement, vestibular / vertigo, weakness / musculoskeletal abnormalities)
• Antihistamine / benxodiazepines
Morse Fall Scale Assessment

Assessment, diagnosis, and intervention against the risk of falling in the nursing field follow the Morse Fall Scale (MFS). MFS is used extensively in acute care conditions, in hospitals and in long-term inpatient care
MFS requires a systematic and reliable assessment of the risk factors for falling in patients at the time of admission, falls, changes in status and discharged or moved to another place. The MFS sub-scale includes an assessment of the following

No Kriteria Skor
1 Riwayat jatuh: baru saja atau dalam 3 bulan Tidak = 0      Ya = 25
2 Diagnosis lain Tidak = 0      Ya = 15
3 Bantuan berjalan Tidak ada, tira baring, di kursi roda, bantuan perawat = 0

Tongkat ketiak (crutch), tongkat (cane), alat bantu berjalan (walker) = 15

Furnitur= 30

4 IV/heparin lock Tidak = 0       Ya = 20
5 Cara berjalan/berpindah Normal, tirah baring, tidak bergerak = 0

Lemah = 10
Terganggu = 20
6 Status mental Mengetahui kemampuan diri = 0

Lupa keterbatasan = 15

Tingkat risiko Skor MFS Tindakan
Tidak Ada Risiko 0-24 Tidak ada
Risiko Rendah 25-50 Lakukan pencegahan jatuh standar
Risiko Tinggi ≥ 51 Lakukan intervensi pencegahan jatuh risiko-tinggi

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