Which test would the nurse perform to assess the risk of fall in a patient diagnosed with a chronic illness?

According to the Centers for Disease Control and Prevention (CDC), falls are a serious threat to the health and well-being of older adults. The specific test a nurse would perform to assess the risk of fall in a patient diagnosed with a chronic illness depends on the patient's setting and mobility. Comprehensive assessments often combine clinical scales with functional tests to determine the most effective fall prevention strategy.

Quick Summary

Several tools are used to assess fall risk in patients with chronic illness, including the Morse Fall Scale, the Timed Up and Go (TUG) test, and the Berg Balance Scale. Each test evaluates different factors, from medical history and diagnoses to functional mobility and balance. The choice of assessment tool is based on the patient's condition and care setting to develop a personalized fall prevention plan.

Key Points

• Morse Fall Scale: A nurse can use the Morse Fall Scale (MFS) for a quick screening to assess fall risk based on factors like history of falls, secondary diagnoses, and mobility status, especially in acute care settings.

• Timed Up and Go Test: The Timed Up and Go (TUG) test is a performance-based assessment that measures mobility by timing how long it takes a patient to stand, walk a short distance, and sit back down.

• Berg Balance Scale: For a more detailed assessment of static and dynamic balance, a nurse might use the Berg Balance Scale (BBS), especially for patients with neurological conditions.

• STEADI Initiative: The CDC's STEADI program provides a comprehensive framework that includes screening, assessing, and intervening to reduce fall risk in older adults with chronic conditions.

• Multifactorial Assessment: Chronic illness often requires a multifactorial assessment that combines clinical scoring tools with functional mobility tests and a review of other risk factors like medication and environmental hazards.

• Nurse's Role: The nurse's role extends beyond testing to implementing personalized interventions, educating patients and families, and reassessing risk over time.

Common tests and scales for fall risk assessment

Nurses utilize a variety of evidence-based tools to assess a patient's risk of falling, especially when a chronic illness may affect mobility, balance, or cognitive function. The selection of a specific test is often tailored to the patient's individual needs and the clinical setting, such as a hospital, long-term care facility, or home care environment. A combination of tests may be used for a more comprehensive evaluation.

Morse Fall Scale (MFS)

The Morse Fall Scale is a widely-used and quick assessment tool, particularly in acute care settings. It uses a simple scoring system based on six clinical variables to classify a patient's risk as low, moderate, or high.

Components evaluated by the MFS:

• History of falling within the last three months (Yes/No)
• Secondary diagnosis (multiple medical conditions increase risk)
• Ambulatory aid (e.g., uses a cane, walker, or relies on furniture)
• IV therapy or heparin lock
• Gait status (e.g., normal, weak, or impaired)
• Mental status (e.g., oriented to own ability versus forgetting limitations)

Timed Up and Go (TUG) Test

The Timed Up and Go (TUG) test is a simple and quick performance-based assessment that measures a person's mobility and balance. It is an excellent screening tool for fall risk in older adults and those with chronic conditions like Parkinson's disease, multiple sclerosis, and stroke.

TUG test procedure:

• The patient sits in a standard armchair.
• On the command "go," the patient stands up.
• The patient walks three meters (about 10 feet) at their normal pace.
• They turn around, walk back to the chair, and sit down.
• The nurse times the task from the command "go" to when the patient is seated again.

A time of 12 seconds or more generally indicates a high risk for falls.

Berg Balance Scale (BBS)

The Berg Balance Scale is a more detailed, 14-item performance-based assessment that evaluates both static and dynamic balance. It is particularly useful for identifying balance deficits in patients with neurological conditions or other chronic illnesses impacting stability. The test takes longer to administer than the TUG, but provides a comprehensive picture of a patient's balance abilities.

CDC's STEADI Initiative

The Centers for Disease Control and Prevention's (CDC) STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative provides a coordinated approach to fall prevention. It is a three-step process designed to help healthcare providers: Screen, Assess, and Intervene. The assessment phase of STEADI integrates various tools, including the TUG and others, to develop a multifactorial assessment.

Factors increasing fall risk in chronic illness

Chronic diseases can significantly increase the risk of falling through several mechanisms. Nurses must consider these underlying factors when interpreting assessment results and formulating care plans.

• Chronic Pain and Arthritis: Conditions like arthritis can cause joint stiffness, reduce range of motion, and decrease physical activity, all of which contribute to muscle weakness and poor balance.
• Neurological Conditions: Diseases such as Parkinson's, stroke, and multiple sclerosis directly impact balance, coordination, and gait through central nervous system dysfunction.
• Cardiovascular Conditions: Irregular heart rhythms, orthostatic hypotension (a drop in blood pressure upon standing), and other heart issues can cause dizziness or lightheadedness, leading to falls.
• Diabetes: Peripheral neuropathy can affect sensation in the feet, impairing balance. In addition, fluctuations in blood sugar can cause dizziness and weakness.
• Vision and Hearing Loss: Impaired vision affects a person's ability to navigate their environment, while hearing loss can impact balance.
• Medication Effects: Many medications used to treat chronic illnesses, including sedatives, diuretics, and blood pressure medications, can cause side effects like drowsiness, dizziness, or orthostatic hypotension. Polypharmacy (taking multiple medications) further compounds this risk.

Comparison of fall risk assessment tools

Assessment Tool	Time to Administer	Key Strengths	Limitations	Ideal For	Scoring
Morse Fall Scale (MFS)	Very quick (< 3 mins)	Quick and easy to use; excellent for screening in busy acute settings.	Primarily relies on self-report and chart review; does not directly test mobility or balance.	Acute care and inpatient settings.	Numerical score classifies risk as low, moderate, or high.
Timed Up and Go (TUG)	Quick (< 1 min)	Simple, objective, and performance-based; easy to administer in various settings.	Can have varied results depending on the patient's effort; single-task assessment.	Screening in community, outpatient, and inpatient settings.	Time in seconds; ≥12 seconds indicates high risk.
Berg Balance Scale (BBS)	Moderate (15-20 mins)	Comprehensive assessment of static and dynamic balance.	Time-consuming; some items can be too challenging for high-risk patients, causing a "floor effect".	Evaluating progress in rehabilitation and neurological conditions.	Total score out of 56; lower scores indicate higher risk.
STEADI Initiative	Varies (multi-component)	Comprehensive, evidence-based program that integrates screening, assessment, and intervention.	Requires coordination and can be complex to implement fully.	Multifactorial risk assessment and long-term prevention programs.	Incorporates scores from multiple tests like TUG and includes medication review.

Conclusion

For a patient with a chronic illness, a nurse would perform an individualized fall risk assessment, often starting with a quick and reliable tool like the Morse Fall Scale or the Timed Up and Go (TUG) test. The specific test chosen depends on the patient's condition and the clinical setting. The nurse’s role goes beyond initial testing to a multifactorial evaluation that considers the patient's medication regimen, chronic conditions, and environmental factors, in line with frameworks like the CDC's STEADI initiative. A comprehensive approach, incorporating physical performance tests and an in-depth review of risk factors, allows the nurse to create a personalized fall prevention plan to enhance patient safety and quality of life.

Nursing interventions and fall prevention

Upon identifying a patient's fall risk, the nurse's role expands to implementing targeted interventions to minimize hazards and promote safety. These interventions may include:

• Environmental modifications: Removing clutter, securing rugs, ensuring adequate lighting, and providing grab bars can help reduce trip hazards at home or in a healthcare facility.
• Medication management: Collaborating with physicians and pharmacists to review medications that may cause dizziness, sedation, or orthostatic hypotension.
• Therapeutic exercise: Referring patients to physical or occupational therapy for programs that build strength, improve balance, and enhance gait.
• Patient education: Educating the patient and their family about identified risks, proper use of mobility aids, and how to safely navigate their environment.
• Use of technology: Using bed alarms, pressure-sensitive floor mats, and wearable devices to monitor high-risk patients.
• Regular reassessment: Continuously monitoring the patient and reassessing their fall risk, especially after a change in medication, health status, or transfer to a different unit.

This multi-pronged approach helps to address the complex nature of fall risk in patients with chronic illnesses and emphasizes the nurse's central role in patient safety.

Frequently Asked Questions

What is the most common test a nurse uses for a patient in a hospital?

In an acute care setting like a hospital, the Morse Fall Scale (MFS) is one of the most commonly used tools due to its simplicity and speed. It helps nurses rapidly determine a patient's risk level based on a few key factors, including a history of falls, secondary diagnoses, and mental status.

How does the nurse use the Timed Up and Go (TUG) test?

To perform the TUG test, the nurse times how long it takes a patient to stand from a chair, walk 10 feet, turn around, walk back, and sit down. A patient taking 12 seconds or more to complete the test is generally considered to be at a high risk for falls.

What factors does a nurse consider for a patient with multiple chronic conditions?

For a patient with multiple chronic conditions, a nurse considers the history of falls, gait and balance, medication effects (including polypharmacy), vision and hearing impairments, and the patient's cognitive status. A multifactorial assessment is necessary to address all contributing risks.

When should a nurse perform a fall risk assessment?

A fall risk assessment should be performed upon patient admission, after any transfer between units, following a fall incident, and whenever there is a significant change in the patient's condition, such as a new medication or decline in mobility.

How does the Berg Balance Scale differ from other tests?

The Berg Balance Scale (BBS) is a more comprehensive and time-intensive assessment than simpler screening tools. It evaluates a patient's balance through 14 functional tasks, providing a more detailed picture of both static and dynamic balance abilities.

What interventions can a nurse implement based on a fall risk assessment?

Interventions based on a fall risk assessment include tailoring the care plan to the patient's needs, such as recommending physical therapy, reviewing medications for side effects, modifying the environment to remove hazards, and educating the patient and family about fall prevention strategies.

Can a nurse use technology to help assess fall risk?

Yes, nurses can utilize technology like bed alarms, video monitoring, and sensor-based devices to monitor patients and supplement standard assessment tools. This technology can alert staff to unsafe movements, particularly for patients with cognitive impairments.