Hester Davis Scale Fall Assessment
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Questions and Answers

What age corresponds to the 'Age' score in the Hester Davis Scale?

  • 50
  • 70
  • 80
  • 60 (correct)

    • What score corresponds to the age 60?

    3

    Which of the following options indicate a Last Known Fall Date? (Select one)

  • No Falls (correct)
  • Within the Last Month (correct)
  • Within the Last Year (correct)
  • During Current Hospitalization (correct)

    • How many falls corresponds to No Falls in the Last Known Fall Date?

    <p>0</p> Signup and view all the answers

    What score corresponds to 'Within the Last Year' in the Last Known Fall Date?

    <p>1</p> Signup and view all the answers

    What score corresponds to 'Within the Last 6 months' in the Last Known Fall Date?

    <p>2</p> Signup and view all the answers

    What score corresponds to 'Within the Last Month' in the Last Known Fall Date?

    <p>3</p> Signup and view all the answers

    What score corresponds to 'During Current Hospitalization' in the Last Known Fall Date?

    <p>4</p> Signup and view all the answers

    What mobility condition corresponds to No Limitations?

    <p>0</p> Signup and view all the answers

    What score corresponds to Dizziness/Generalized Weakness in Mobility?

    <p>1</p> Signup and view all the answers

    What score corresponds to Immobilized/Requires Assist of One Person in Mobility?

    <p>2</p> Signup and view all the answers

    What score corresponds to Use of Assistive Device/Requires Assist of 2 People in Mobility?

    <p>3</p> Signup and view all the answers

    What score corresponds to Hemiplegic, Paraplegic, Quadriplegic in Mobility?

    <p>4</p> Signup and view all the answers

    Which of the following medications corresponds to No Meds?

    <p>No Meds</p> Signup and view all the answers

    What score corresponds to CV or CNS Meds?

    <p>1</p> Signup and view all the answers

    What score corresponds to CV and CNS Meds?

    <p>2</p> Signup and view all the answers

    What score corresponds to Diuretics?

    <p>3</p> Signup and view all the answers

    What score corresponds to Chemo in last month?

    <p>4</p> Signup and view all the answers

    What is the score for A, A, Ox3 (awake, alert, oriented x 3)?

    <p>0</p> Signup and view all the answers

    What score corresponds to Lethargic/Oriented to Person Only?

    <p>2</p> Signup and view all the answers

    What score corresponds to Unresponsive/Noncompliance with Instructions?

    <p>4</p> Signup and view all the answers

    Which of the following indicates No Need for toileting?

    <p>No Need</p> Signup and view all the answers

    What score corresponds to Use of Catheter or Diversion Device?

    <p>1</p> Signup and view all the answers

    What score corresponds to Incontinence?

    <p>3</p> Signup and view all the answers

    Which of the following indicates No Problem in Volume/Electrolyte Status?

    <p>No Problem</p> Signup and view all the answers

    What score corresponds to NPO>24 hrs?

    <p>1</p> Signup and view all the answers

    What score corresponds to Low Blood Sugar/Electrolyte Imbalance?

    <p>4</p> Signup and view all the answers

    What is the score for Appropriate Behaviour?

    <p>0</p> Signup and view all the answers

    What score corresponds to Behavioral Non-compliance with Instructions?

    <p>2</p> Signup and view all the answers

    What score corresponds to Etoh/Substance Abuse?

    <p>3</p> Signup and view all the answers

    What total score indicates the need to implement a fall protocol?

    <p>7 or greater</p> Signup and view all the answers

    What is the score range for Low Risk?

    <p>7-10</p> Signup and view all the answers

    What is the score range for Mod Risk?

    <p>11-14</p> Signup and view all the answers

    What score denotes High Risk?

    <p>15 or greater</p> Signup and view all the answers

    Study Notes

    Hester Davis Scale (HDS) Overview

    • The Hester Davis Scale is used for fall risk assessment in patients.
    • Each component of the assessment receives a score based on specific criteria.

    Key Assessment Factors

    • Age: Age is weighted heavily in scoring, with 60 years associated with a score of 3.
    • Last Known Fall Date:
      • No falls = 0
      • Within the last year = 1
      • Within the last 6 months = 2
      • Within the last month = 3
      • During hospitalization = 4
    • Mobility Limitations:
      • No limitations = 0
      • Dizziness/generalized weakness = 1
      • Immobilized or requires assistance = 2
      • Uses assistive device or requires significant help = 3
      • Hemiplegic, paraplegic, or quadriplegic = 4

    Medications Impact

    • No medications = 0
    • CV (cardiovascular) or CNS (central nervous system) medications = 1
    • Both CV and CNS medications = 2
    • Use of diuretics = 3
    • Recent chemotherapy = 4

    Mental Status and Awareness

    • Fully alert and oriented (A & O x3) = 0
    • Oriented to person or place = 1
    • Lethargic or only oriented to person = 2
    • Confused and needs reorientation = 3
    • Unresponsive or noncompliant = 4

    Toileting Needs

    • No need for assistance = 0
    • Use of catheter or diversion device = 1
    • Requires assistive device = 2
    • Incontinence = 3
    • Diarrhea, frequency, or urgency = 4

    Volume and Electrolyte Status

    • No issues = 0
    • NPO (nothing by mouth) for more than 24 hours = 1
    • Use of IV fluids or tube feeding = 2
    • Nausea/vomiting = 3
    • Low blood sugar or electrolyte imbalances = 4

    Communication and Sensory Deficits

    • No sensory deficits = 0
    • Visual or hearing impairment = 1
    • Language barriers or slurred speech = 2
    • Neuropathy = 3
    • Blindness or recent visual changes = 4

    Behavioral Assessment

    • Displays appropriate behavior = 0
    • Signs of depression or anxiety = 1
    • Non-compliance with instructions = 2
    • Alcohol or substance abuse = 3
    • Impulsivity = 4

    Total Risk Score Interpretation

    • Total score of 7 or higher indicates the need to implement fall prevention protocols.
    • Risk categories:
      • Low Risk: Score of 7-10
      • Moderate Risk: Score of 11-14
      • High Risk: Score of 15 or greater

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    Description

    Test your knowledge on the Hester Davis Scale for fall assessments. This quiz includes flashcards covering critical definitions and criteria related to patient age and fall history. Perfect for healthcare professionals looking to reinforce their understanding of fall risk assessment.

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