BKJ-BOR-PPK-Fall 6 Pind 1/2018

BAHAGIAN KEJURURAWATAN

HUMPTY DUMPTY FALL RISK ASSESSMENT SCALE CHART(PAEDIATRIC)

Name: Age:

RN No: Ward:

DATE

TIME

SCORE SCORE SCORE SCORE SCORE SCORE SCORE SCORE

<3 years old 43 years to < 7 years old 37 years to , 13 years old 213 years + 1

Male 2Female 1

Neurological Diagnosis 4

3

2

1

Not aware of limitations 3

Forgets limitations 2

Oreintated to own ability 1

4

3

Patient placed in bed 2

Out-patient area 1

Patient had Surgery/Deep Sedation

Within 24 hours 3

Within 48 hours 2

More than 48 hours/None 1

3

2

Other Medications/None 1

*Low Fall Risk = 7-11 (Initiate low risk standard protocol)

*High Fall Risk = ≥ 12 (Initiate high risk standard protocol)

KEMENTERIAN KESIHATAN MALAYSIA

PARAMETER

Cognitive Impairement

Environmental Factors

Medication Usage

Age

Gender

Diagnosis

Alteration in oxygenation(eg

Respiratory Diagnosis,

Dehydration, Anaemia,

Syncope/Diziness etc.

Psychological/Behavioral

Disorders

Other Diagnosis

History of falls Infant -

Toddler placed in bed

Patient uses assistive devices

Multiple usage of

Sedatives(Excluding ICU);

Hypnotics; Barbiturates;

Antidepressants;laxative;Diuretic

s; Narcotic

Deborah H.R.et.al 2008

One of the medications listed

above

TOTAL SCORE

Name & Signature