Using the Morse Fall Risk scale (see exhibit), the nurse should initiatehighest fall risk precautions for which of the following clients?
1. 84-year-old client with diabetes admitted with new-onset confusion. The client reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock.
2. 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter.
3. 62-year-old client with a history of Parkinson’s disease, admitted for pneumonia and receiving IV antibiotics. The client has fallen at home butis able to ambulate with a cane. During his hospitalization, he has gotten out of bed without calling for assistance.
4. 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes per day; may be up independently; and has steady gait.
Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no.
1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points).
CN: Safety and infection control; CL: Analyze