This assessment identifies individuals living in extended care and over the age of 65 at risk for developing pressure ulcers.

MENTAL STATUS Unconscious (1) — nonresponsive to painful stimuli
Stuporous (2) — total disorientation. Does not respond to name, simple commands or verbal stimuli.
Confused (3) — partial and/or intermittent disorientation to temperature, pulse and respiration. Purposeless response to stimuli. Restless, aggressive, irritable, anxious and may require tranquilizers or sedatives.
Apathetic (4) — lethargic, forgetful, drowsy, passive and dull, sluggish, and depressed. Able to obey simple commands. Possibly disoriented to time.
Alert (5) — oriented to time, place and person. Responsive to all stimuli and understands explanations.
CONTI-NENCE Absence of control (1) — incontinent of both urine and feces
Minimally controlled (2) — often incontinent of urine with occasional to frequent incontinence of feces
Usually controlled (3) — incontinent of urine and/or feces once in a while, or has Foley catheter and is incontinent of feces
Fully controlled (4) — total control of urine and feces
MOBILITY Immobile (1) — cannot change position without assistance. Is completely dependent on others for movement.
Very limited (2) — with some assistance, can change position. May have contractures, paralyses, etc.
Slightly limited (3) — can control and move all extremities but with some limitations. Requires the assistance of another person to change position.
Full (4) — can control and move all extremities at will. May need a device, but can turn, lift, pull, balance and attain sitting position at will.
ACTIVITY (ability to walk) Bedfast (1) — is confined to bed during entire 24-hour day.
Chairfast (2) — walks only to a chair; requires assistance to do so or is confined to a wheelchair.
Walks with help (3) — can walk with assistance of another person, braces, or crutches. May have limitation on stairs. May have unsteady gait.
Ambulatory (4) — can walk unassisted. Rises from bed unassisted. With a cane or walker, can ambulate without assistance.
NUTRITION Poor (1) — seldom eats a complete meal; eats only a few bits of food a meal. Is dehydrated and has minimal fluid intake.
Fair (2) — occasionally refuses a meal or frequently leaves the larger portion of a meal. Must be encouraged to take fluids.
Good (3) — eats some food from each category of the Basic Four every day. Drinks 6-8 glasses of fluid every day. Eats the major portion of each meal served or is receiving tube feedings.
SKIN STATUS Skin appearance (description of observed skin characteristics): dry, oily, wrinkled, scaly, flaccid and so on.
Skin tone (degree of turgor and tension of the skin determined by pinch at specific high-risk sites for pressure sores): hard, moderate, loose.
Skin sensation (response of an individual to tactile stimuli of the epidermis. Identified high-risk sites for pressure sores stimulated for touch and two-point discrimination): None, slight, moderate, great.
Text field: enter notes describing skin (optional)
SCORING The five scores are summed. The result is an indicator of risk for developing pressure ulcers. 5 is the worst prognosis. 20 is the best prognosis. Complete evaluation also includes recording of vital signs, skin condition and medications, but these are not scored.

This assessment identifies patients who suffer from hearing deficit and may be handicapped by it.

Instructions: Answer Yes, No, or Sometimes for each question. Do not skip any questions even if your patient avoids a situation because of a hearing problem. If your patient uses a hearing aid, please answer according to the way they hear with the aid.

  1. Does a hearing problem cause you to feel embarrassed when you meet new people?
  2. Does a hearing problem cause you to feel frustrated when talking to members of your family?
  3. Do you have difficulty hearing when someone speaks in a whisper?
  4. Do you feel handicapped by a hearing problem?
  5. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?
  6. Does a hearing problem cause you to attend religious services less often than you would like?
  7. Does a hearing problem cause you to have arguments with family members?
  8. Does a hearing problem cause you difficulty when listening to TV or radio?
  9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life?
  10. Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

Scoring: No = 0; Sometimes = 2; Yes = 4.

  • 0-8: No handicap
  • 9-25: Mild to moderate handicap
  • 26-40: Severe handicap

Equivalent Score in Minimum Data Set
(U.S. Centers for Medicare & Medicaid Services)

Score Interpretation
0-8HEARS ADEQUATELY — normal talk, TV, phone
9-25MINIMAL DIFFICULTY when not in quiet setting
26-35HEARS IN SPECIAL SITUATIONS ONLY — speaker has to adjust tonal quality and speak distinctly
36-40HIGHLY IMPAIRED — absence of useful hearing

This assessment identifies patients who are at risk for readmission or death within thirty days of discharge. It uses four parameters:

  • "L": the length of stay of the admission
  • "A": the acuity of the admission (emergency or elective)
  • "C": co-morbidities (the Charlson Co-Morbidity Index)
  • "E": the number of Emergency Department visits within the last 6 months

LACE scores range from 1 to 19:

  • 0-4: Low probability of readmission or death within thirty days of discharge
  • 5-9: Moderate probability of readmission or death within thirty days of discharge
  • ≥10: High probability of readmission or death within thirty days of discharge

Length of Stay Days Score
1 1
2 2
3 3
4–6 4
7-13 5
14+ 7
Acuity of admission If patient was admitted via the ED 3
If patient was not admitted via the ED 0
Comorbidities Previous MI 1
Cerebrovascular disease 1
Peripheral vascular disease 1
Diabetes without complications 1
Congestive heart failure 2
Diabetes with end organ damage 2
Chronic pulmonary disease 2
Mild liver or renal disease 2
Any tumor (including lymphoma or leukemia) 2
Dementia 3
Connective tissue disease 3
AIDS 4
Moderate or severe liver or renal disease 4
Metastatic solid tumor 6
Emergency department visits How many times the patient has visited an emergency department in the six months prior to admission (not including the emergency department visit immediately preceding the current admission) Score is this number or 4, whichever is smaller.
Calculation Total When button is pressed, total the above scores and display it in a pop-up with one of the following:
0-4 Low probability of readmission or death within thirty days of discharge
5-9 Moderate probability of readmission or death within thirty days of discharge
≥10 High probability of readmission or death within thirty days of discharge

Answer every question.

Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake

Weight loss during the last 3 months

0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss

Mobility

0 = bed or chair bound
1 = able to get out of bed / chair but does not go out
2 = goes out

Has suffered psychological stress or acute disease in the past 3 months?

0 = yes
2 = no

Neuropsychological problems

0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems

Body Mass Index (BMI) (weight in kg) / (height in m squared)

0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater

If BMI is not available, use calf circumference in cm

0 = CC less than 31
3 = CC 31 or greater

Scoring

ScoreInterpretation
12-14NORMAL NUTRITIONAL STATUS
8-11AT RISK OF MALNUTRITION
0-7MALNOURISHED

The Morse Fall Scale (MFS) is a rapid and simple method of determining a patient's likelihood of falling. A large majority of nurses (82.9%) rate the scale as "quick and easy to use," and 54% estimated that it took less than 3 minutes to rate a patient. The MFS consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care, hospital, rehabiliation and nursing homes.

Scoring and Risk Level: The MFS score is tallied and recorded on the patient's chart. Risk level and appropriate interventions are then identified. The six variables are:

  • History of falling; immediate or within 3 months
  • Secondary diagnosis is present
  • Ambulatory aid
  • IV/Heparin Lock
  • Gait
  • Mental status

MFS scores range from 0 to 125:

  • 0-24: Low risk
  • 25-45: Moderate risk
  • 46+: High risk

References