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 (D)</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 (D)</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 (D)</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 (D)</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 (D)</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 (A)</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

Flashcards

Hester Davis Scale

Tool for assessing fall risk in patients based on various factors.

Being 60 Years Old

Assigns a score of 3 in the Hester Davis Scale.

No falls (HDS)

0 points indicate no recent falls.

Falls within last year (HDS)

1 point indicates falls within the past year.

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No mobility limitations (HDS)

Mobility rated as no limitations = 0

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Dizziness/weakness (HDS)

Mobility rated as dizziness/generalized weakness = 1.

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No medications (HDS)

No medications = 0 points assigned.

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CV/CNS meds (HDS)

CV or CNS medications = 1 point assigned.

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Alert & oriented x3 (HDS)

A & O x3 = 0 points assigned.

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Oriented to person/place (HDS)

Oriented only to person or place = 1 point.

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No toileting assistance (HDS)

No assistance needed = 0 points assigned.

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Catheter use (HDS)

Catheter or diversion device = 1 point.

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No fluid/electrolyte issues (HDS)

No fluid or electrolyte issues = 0 points assigned.

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NPO > 24 hours (HDS)

NPO for > 24 hours = 1 point.

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No deficits (HDS)

No sensory deficits present = 0 points.

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Vision/hearing issues (HDS)

Visual or hearing impairment = 1 point.

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Appropriate behavior (HDS)

Appropriate behavior = 0 points on the HDS.

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Depression/anxiety (HDS)

Signs of depression or anxiety = 1 point.

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Low Fall Risk

Score of 7-10.

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Moderate Fall Risk

Score of 11-14.

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High Fall Risk

Score of 15 or greater.

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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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