HUMPTY DUMPTY FALL RISK

ASSESSMENT
Consist of 7 parameters
Minimum score per parameter : 1
Highest score : 23
Lowest score : 7
Interpretation :
7-11 : Low risk
>12 : High risk
 Age & Gender
PARAMETER CRITERIA SCORE

< 3years old

AGE 3 to <7years old
7 to < 13 years old
13 years old
Male
GENDER Female
 Diagnosis
PARAMETER CRITERIA SCORE
Neurological Diagnosis 4
DIAGNOSIS Alteration in Oxygenation 3
Psych/Behavioral Disorder 2
Other Diagnosis 1
 Cognitive Impairment
PARAMETER CRITERIA SCORE
Not aware of limitations 3
COGNITIVE Forget limitations 2
IMPAIRMENT Orientated to own ability 1
 Environmental Factor
PARAMETER CRITERIA SCORE

ENVIRONMENTAL History of falls or infant-toddler 4

FACTORS placed in bed
Uses assistive device or infant-
3
toddler in crib or youth bed
Patient place in bed 2
Outpatient area 1
 Responses to Surgery/ Sedation/
Anesthesia
PARAMETER CRITERIA SCORE

RESPONSES Within 24hours

TO SURGERY / Within 48hours
SEDATION /
ANESTHESIA More than 48hours/none
 Medication Usage
PARAMETER CRITERIA SCORE

MEDICATION Multiple usage of sedative,

hypnotics, barbiturates, anti-
USAGE depressants, laxative, diuretics , 3
narcotics
One of the medication above 2
Other medication/ None 1
 LOW FALLS RISK INTERVENTIONS FOR PAEDIATRIC
POPULATION ( SCORE 7-11 )
1 . ORIENTATION Orientate new surrounding to caretaker.

2. HOSPITAL Advice on use of non-skid footwear for patients who ambulate.

ATTIRE Avoid oversize clothing to prevent risk of tripping.

3. CALL BELL Place a call bell within caretaker‘s reach.

Teach caretaker on how & when to use call bell.

4. BED & LOCKED Appropriate child cot/bed.

WHEEL Keep child cot/bed in lowest position.
Lock the wheels of bed, cupboard or locker.

5. ENVIRONMENT To look out for environmental hazards that may cause a fall.
To keep bathroom / rooms well lit & the floor dry.
Adequate lighting
 LOW FALLS RISK INTERVENTIONS FOR PAEDIATRIC
POPULATION ( SCORE 7-11 )

6. EDUCATION Avoid putting child alone on bench/chair.

To pull up both cot rails if caretaker not attending the child.
Avoid caretaker share child cot/bed with patient.
For video show on fall prevention daily.

7. DOCUMENTATION Documenton fall assessment & intervention been carrying out.

 HIGH FALLS RISK INTERVENTIONS FOR PAEDIATRIC
POPULATION ( SCORE 12 OR MORE )

1 . SIGNAGE Apply a “RED” signage at patient’s bed.

2. 4 HOURLY Do safety checks-staff/Dr to pull up cot rails if

REVIEW caretaker not around.
Emphasize on fall education every shift.

3. MEDICATION Evaluate medication administration times.

** High risk patient ; provide low + high falls risk interventions.

 Patient Details
Name : Patient A
Age : 10 years old
Gender : Male
Date of Birth : 28th January 2013
Race : Chinese
RN : 15050
Date of Admission : 28th July 2023
Diagnosis : Status epilepticus secondary to viral
meningoencephalitis underling MELAS
SYNDROME with cortical blindness
 Chronology of the incident :
SN F heard fall sound while writing report at acute cubicle.
Attended STAT to situation & patient found lying on the floor.
According to mother, child slipped down between bedside
rails ( picture ) & child was accidentally fall down backward &
knocked over head. Brought up the patient to bed STAT. Dr.G
& NS T informed STAT. Vital sign taken post situation , Temp :
36.6, Heart Rate : 143/min, Respiration Rate : 21/min, SPO2 :
96%-98% & BP : 123/76mmHg . Post incident, no loss of
consciousness, GCS : 15/15, both pupils 3mm/3mm. Head to
toe examination done. No external injury/bruises noted. No
tenderness when palpitation of head, swelling of right parietal
temporal.
 IMMEDIATE ACTION FOLLOWING
INCIDENT :

Brought up to bed stat.

Change bed to child cot immediatel.
Suggested to mother to move child to
acute bed for close monitoring but
mother refused as child will disturb
other patients.
THANK YOU
VERY MUCH!