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TINETTI BALANCE ASSESSMENT TOOL, Summaries of Nursing

Patient is seated in hard, armless chair; P.T.O. Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. ( ...

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TINETTI BALANCE ASSESSMENT TOOL
Tinetti ME, Williams TF, Mayewski R, Fall Risk Index for elderly patients based on number of chronic dis-
abilities. Am J Med 1986:80:429-434
PATIENTS NAME ______________________ D.o.b. ___________ Ward ______
BALANCE SECTION
Patient is seated in hard, armless chair;
P.T.O.
Date
Sitting Balance Leans or slides in chair = 0
Steady, safe = 1
Rises from chair
Unable to without help = 0
Able, uses arms to help = 1
Able without use of arms = 2
Attempts to rise
Unable to without help = 0
Able, requires > 1 attempt = 1
Able to rise, 1 attempt = 2
Immediate standing
Balance (first 5 seconds)
Unsteady (staggers, moves feet, trunk sway) = 0
Steady but uses walker or other support = 1
Steady without walker or other support = 2
Standing balance
Unsteady = 0
Steady but wide stance and uses support = 1
Narrow stance without support = 2
Nudged
Begins to fall = 0
Staggers, grabs, catches self = 1
Steady = 2
Eyes closed Unsteady = 0
Steady = 1
Turning 360 degrees
Discontinuous steps = 0
Continuous = 1
Unsteady (grabs, staggers) = 0
Steady = 1
Sitting down
Unsafe (misjudged distance, falls into chair) = 0
Uses arms or not a smooth motion = 1
Safe, smooth motion = 2
Balance score /16 /16
50
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TINETTI BALANCE ASSESSMENT TOOL

Tinetti ME, Williams TF, Mayewski R, Fall Risk Index for elderly patients based on number of chronic dis-

abilities. Am J Med 1986:80:429-

PATIENTS NAME ______________________ D.o.b. ___________ Ward ______

BALANCE SECTION

Patient is seated in hard, armless chair;

P.T.O.

Date

Sitting Balance

Leans or slides in chair = 0 Steady, safe = 1

Rises from chair

Unable to without help = 0 Able, uses arms to help = 1 Able without use of arms = 2

Attempts to rise

Unable to without help = 0 Able, requires > 1 attempt = 1 Able to rise, 1 attempt = 2

Immediate standing

Balance (first 5 seconds)

Unsteady (staggers, moves feet, trunk sway) = 0 Steady but uses walker or other support = 1 Steady without walker or other support = 2

Standing balance

Unsteady = 0 Steady but wide stance and uses support = 1 Narrow stance without support = 2

Nudged

Begins to fall = 0 Staggers, grabs, catches self = 1 Steady = 2

Eyes closed

Unsteady = 0 Steady = 1

Turning 360 degrees

Discontinuous steps = 0 Continuous = 1

Unsteady (grabs, staggers) = 0 Steady = 1

Sitting down

Unsafe (misjudged distance, falls into chair) = 0 Uses arms or not a smooth motion = 1 Safe, smooth motion = 2

Balance score /16 /

50

TINETTI BALANCE ASSESSMENT TOOL

GAIT SECTION

Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace.

Risk Indicators:

Tinetti Tool Score Risk of Falls

18 High

19-23 Moderate

24 Low

Date

Indication of gait

(Immediately after told to ‘go’.)

Any hesitancy or multiple attempts = 0 No hesitancy = 1

Step length and height

Step to = 0 Step through R = 1 Step through L = 1

Foot clearance

Foot drop = 0 L foot clears floor = 1 R foot clears floor = 1

Step symmetry

Right and left step length not equal = 0 Right and left step length appear equal = 1

Step continuity

Stopping or discontinuity between steps = 0 Steps appear continuous = 1

Path

Marked deviation = 0 Mild/moderate deviation or uses w. aid = 1 Straight without w. aid = 2

Trunk

Marked sway or uses w. aid = 0 No sway but flex. knees or back or uses arms for stability = 1 No sway, flex., use of arms or w. aid = 2

Walking time

Heels apart = 0 Heels almost touching while walking = 1

Gait score /12 /

Balance score carried forward /16 /

Total Score = Balance + Gait score /28^ /

51