ASSIGNMENT RISK OF FALL

” Morse scale, humpty dumpty, and sydney”

Created by:
1. Sinatria Krisdayanto (P1337420618059)
2. Renita Wahyuni (P1337420618062)
3. Gita Ayu Asmarani (P1337420618069)

UNDERGRADUATE NURSING APPLIED SCIENCE

DEPARTMENT OF NURSING
HEALTH POLYTECHNIC OF SEMARANG
2018

PREFACE
First of all, the writer wants to express his thanks to Allah SWT, because of His bless
and grace, the entitled ” The Intrinsic Element of The Happy Prince Short Story” can
be finished on time. Evidence-based patient assessment instruments, such as the
Morse Fall Risk Scale, are reliable and valid assessments when used as designed.
Understanding the process nurses use when implementing the Morse Fall Risk Scale
is important for preventing falls. This single explanatory case study used the
components of high reliability theory to examine how medical-surgical staff nurses
implement an evidence-based fall risk assessment instrument. Data was collected
from an evidence-based belief survey, observations, interviews, staff and leader
education records, and a review of the organizational policy and patient electronic
health records. The collected quantitative and qualitative data was first analyzed
separately and then triangulated, matching empirical patterns to propositional
statements to explain the nurse’s process for implementing the Morse Fall Risk Scale.
The study location and sample were described to provide context for the case study.
The initial sample included 24 medical-surgical staff nurses and four organizational
leaders who completed the Evidence-Based Practice Belief Scale. Observations of the
implementation of the Morse Fall Scale included ten medicalsurgical nurses who
participated in the survey, while seven of the observed nurses also participated in
semi-structure interviews. The four organizational leaders were also interviewed. The
nurse’s high level of evidence-based practice belief and perception that more support
than barriers existed for conducting the assessment explained the consistency in
implementing the Morse Fall Risk Scale. The elements of the high reliability theory
explained the majority of the data, however new concepts emerged, including
management role, forces impeding high reliability, nurses managing roles, judgment,
and other considerations

Semarang , January 1st, 2019

Autho

CONTENT
More than 400 risk factors are associated with falls, many of which are modifiable
( Masud and Morris 2001 ). Risk factors for falls are often classified into two
categories: intrinsic risk factors which are related to patient conditions, and extrinsic
risk factors which are related to environmental or organisational factors ( Masud and
Morris 2001 ). It important to note that falls among older inpatients are often caused
by a synergic combination of intrinsic and extrinsic risk factors. Several intrinsic risk
factors are relevant for older people. Many age-related chronic conditions are
associated with an increased risk of falls. For example, Parkinson's disease causes
musculature and joint rigidity, slowness in initiating movement and postural
instability. Stroke, degenerative joint diseases and arthritis may also cause muscle
weakness or impair balance or gait. Older patients with diabetes are at increased risk
of falls compared to patients who do not have diabetes. Other conditions associated
with an increased risk of falls include: altered mental status, confusion, delirium,
cognitive impairment, urinary incontinence, depression and postural hypotension
( Todd and Skelton 2004 ). Visual impairment is an important falls risk factor; older
patients with suboptimal vision as a result of cataract, glaucoma or macular
degeneration are increasingly likely to fall and experience fractures as a result ( Todd
and Skelton 2004 ). Bifocal or multifocal lenses often contribute to the risk of falls
because they alter perception of distances ( Todd and Skelton 2004 ). Medication
taken by patients is an important risk factor, especially psychotropic, antipsychotic
and antidepressant, antidiabetic, antiarrhythmic, antihypertensive, diuretic and
hypnotic medication. The risk of falls increases if the patient is taking more than four
medications, irrespective of the types of medication ( Todd and Skelton 2004 ). Fear
of falling has been shown to correlate with suboptimal postural performance, slower
walking speed and muscle weakness ( Todd and Skelton 2004 ). Foot problems, for
example bunions, toe deformities, ulcers, deformed nails and pain when walking can
compound difficulties in maintaining balance, thus increasing the risk of falls ( Todd
and Skelton 2004 ). Non-medical factors associated with healthcare may also increase
the risk of falls, such as a prolonged hospital stay, a history of falls or care
dependency ( Zhao and Kim 2015 ). The environmental risk factors that frequently
contribute to falls in older inpatients include: low or inadequate lighting, slippery
floors, badly fitting footwear or clothing, bed rails and assistive devices, such as
sticks, walking frames or wheelchairs. Characteristics of care staff and the care
setting can also contribute to falls in older inpatients. Falls occur more frequently in
older people's units, internal medicine and neurological units, mostly during shift
changes or during night and evening shifts ( Zhao and Kim 2015 ). Certain patient
activities are associated with an increased risk of falls, such as walking, transferring,
for example from sitting to standing position, or attending to urinary or bowel
elimination needs ( Zhao and Kim 2015 ).

Morse Fall Scale

(Adapted with permission, SAGE Publications)
 The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s
likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and
easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. It
consists of six variables that are quick and easy to score, and it has been shown to
have predictive validity and interrater reliability. The MFS is used widely in acute
care settings, both in the hospital and long term care inpatient settings.

Item Scale Scoring

1. History of falling; immediate or No 0 ______
within 3 months Yes 25
No 0 ______
2. Secondary diagnosis
Yes 15
3. Ambulatory aid ______
0
Bed rest/nurse assist
15
Crutches/cane/walker
30
Furniture
No 0 ______
4. IV/Heparin Lock
Yes 20
5. Gait/Transferring ______
Normal/bedrest/immobile
0 10 20
Weak
Impaired
6. Mental status ______
Oriented to own ability 0 15
Forgets limitations

The items in the scale are scored as follows:

History of falling: This is scored as 25 if the patient has fallen during the present
hospital admission or if there was an immediate history of physiological falls, such as
from seizures or an impaired gait prior to admission. If the patient has not fallen, this
is scored 0. Note: If a patient falls for the first time, then his or her score immediately
increases by 25.
Secondary diagnosis: This is scored as 15 if more than one medical diagnosis is listed
on the patient’s chart; if not, score 0.
Ambulatory aids: This is scored as 0 if the patient walks without a walking aid (even
if assisted by a nurse), uses a wheelchair, or is on a bed rest and does not get out of
bed at all. If the patient uses crutches, a cane, or a walker, this item scores 15; if the
patient ambulates clutching onto the furniture for support, score this item 30.
Intravenous therapy: This is scored as 20 if the patient has an intravenous apparatus
or a heparin lock inserted; if not, score 0.

Gait: A normal gait is characterized by the patient walking with head erect, arms
swinging freely at the side, and striding without hesitant. This gait scores 0. With a
weak gait (score as 10), the patient is stooped but is able to lift the head while
walking without losing balance. Steps are short and the patient may shuffle. With an
impaired gait (score 20), the patient may have difficulty rising from the chair,
attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by
using several attempts to rise). The patient’s head is down, and he or she watches the
ground. Because the patient’s balance is poor, the patient grasps onto the furniture, a
support person, or a walking aid for support and cannot walk without this assistance.
Mental status: When using this Scale, mental status is measured by checking the
patient’s own self-assessment of his or her own ability to ambulate. Ask the patient,
“Are you able to go the bathroom alone or do you need assistance?” If the patient’s
reply judging his or her own ability is consistent with the ambulatory order on the
Kardex®, the patient is rated as “normal” and scored 0. If the patient’s response is not
consistent with the nursing orders or if the patient’s response is unrealistic, then the
patient is considered to overestimate his or her own abilities and to be forgetful of
limitations and scored as 15.
Scoring and Risk Level: The score is then tallied and recorded on the patient’s chart.
Risk level and recommended actions (e.g. no interventions needed, standard fall
prevention interventions, high risk prevention interventions) are then identified.

Sample Risk Level Risk Level MFS Score Action

Good Basic Nursing
No Risk 0 - 24
Care
Implement Standard
Low Risk 25 - 50 Fall Prevention
Interventions
Implement High Risk
High Risk ≥ 51 Fall Prevention
Interventions
Important Note: The Morse Fall Scale should be calibrated for each particular
healthcare setting or unit so that fall prevention strategies are targeted to those most at
risk. In other words, risk cut off scores may be different depending on if you are using
it in an acute care hospital, nursing home or rehabilitation facility. In addition, scales
may be set differently between particular units within a given facilit
 THE HUMPTY DUMPTY FALL SCALE

Humpty Dumpty Scale This study is an assessment of the risk of falling for the kids. This
study contains some items used to assess the risk of falling of the patient i.e. age, gender,
diagnosis, disorders, cognitive factors environment, response to surgery, sedation, anesthesia,
and as well as the use of drugs (Rodriguez, et al., 2009). The level of Humpty Dumpty falls
risk based on Scale partitioned into two 7-11 for a low risk score and score ≥ 12 for the
higher risk.

Preventing patient falls begins with an accurate assessment of a patient’s risk of falling
followed by the initiation and continued evaluation of a fall prevention program based on
patient-specific identified risks. Children have a normal tendency to fall based on
developmental growth, and each child is different in physical and cognitive abilities. Falls
may occur both in and out of the hospital setting. Prevention programs that have revealed the
most favorable results include the use of a validated fall risk assessment tool. The Humpty
Dumpty Fall Scale is a screening tool specifically developed for pediatric patients to assess
risk for fall. This project developed a pediatric fall prevention policy and implemented an
inpatient pediatric fall prevention program. Pediatric staff contributed to the development of
this policy and program by providing feedback, support, and cooperation, which was
instrumental in the success of this program resulting in no falls after implementation.

With pediatric patients at a high risk for injury due to falls, The Joint Commission
recommends each hospital have a method of identifying and screening children at risk (Rouse
et al., 2014). Preventing patient falls begins with an accurate assessment of a patient’s risk of
falling followed by issues, may be at greater risk for falling (Harvey, Kramlich, Chapman,
Parker, & Blades, 2010). Each child is different in physical and cognitive abilities. As
children grow and develop, they approach mobility in different ways; infants crawl, toddlers
stumble with unsteady gait, pre-school children climb and hang, school-age children must be
told to walk and not run, and adolescents can be daredevils (Kramlich & Dende, 2016).
Although falls may occur both in and out of the hospital setting, a hospitalized child’s
medical condition, treatments, and medications can further compromise normal
developmental and prospective control, placing them at an increased risk for falls. Pediatric
patient falls are categorized as physical, physiologically anticipated, physiologically
unanticipated, response to treatment, developmental, roughhousing, or accidental (Ryan-
Wenger & Dufek, 2013). Prevention of falls in the hospitalized pediatric patient population is
an important aspect of care. Both healthcare providers and parents should understand that
hospitalized children are at an increased risk for falls related to a new environment, impaired
gait, and possible disorientation related to illness (Razmus, Wilson, Smith, & Newman,
2006). Pediatric nurses who provide direct patient care are vital in protecting patients from
falls and are generally those who report falls (Kramlich & Dende, 2016). The possibility of
underreporting by staff is a cause for concern because falling can be normal in the pediatric
population related to age and developmental growth (Pauley et al., 2014). To address this
problem, a valid and reliable tool for screening for fall risk in the pediatric population is
necessary. Currently, there are several pediatric screening assessment tools, such as General
Risk Assessment for. Pediatric Inpatient Falls (Graf-PIF), CHAMPS, Cummings scale,
Children’s National Medical Center (CNMC) scale, and the Humpty Dumpty Fall Scale
(Kramlich & Dende, 2016). For this project, the Humpty Dumpty Fall Scale screening tool
was used to increase awareness of patients who are at risk for falls and to decrease the rate of
falls of pediatric patients in the hospital setting. The Humpty Dumpty Fall Scale is
specifically developed for pediatric patients to assess risk for fall. The tool is broken down
into categories consisting of age, sex, diagnosis, cognitive impairments, environmental
factors, response to surgery/anesthesia/sedation, and medication usage. Based on scores,
pediatric patients are placed into two categories, either low risk (< 12) or high risk (> 12)
(Rouse et al., 2014).
 SCALE SYDNEY

based on the decision of the Director of PKU Muhammadiyah Limestone number 1636/SK.
3.2/X/2016 on A Guide To Risk Management Of Patients Falling, PKU Muhammadiyah
Limestone using three types of assessment risk of falling include Morse Fall Score for adult
patients IE:

1) Sydney Scoring

The Sydney Scoring is another name of Ontario Modified Stratify. This study is the
adaptation of the STRATIFY in the setting in Australia Hospital. Sydney The score is used to
assess the risk of falls in patients old age (elderly). The study of Sydney's Scoring load
factors related to the incidence of falls as a history of falls, mental status, vision, toileting,
transfer from wheelchair to bed, and also score mobility (the Australian Commission on
Safety and Quality in Healthcare, 2009). Fall risk category based on the total the study of the
Sydney Scoring i.e. score for risk 0-5 low, 6-16 to 17-30, and the risk of being a risk to
height.
Ontario Modified Stratify -SS MR Number……………………
Falls Risk Screening Surname ……………………….
Please read instructions for use Date of Birth …………………..
Please fill in if no patient label is
available
Date: / /
Item Falls Risk Value Score
Screening
Assessment
1. History of falls. Did the patient present to Yes to any = 6
hospital with a fall or
have they fallen since
admission? No Yes

If not, has the patient
fallen within the last 2
months? No Yes 
2. Mental Status Is the patient confused Yes to any = 14
(i.e. unable to make
purposeful decisions,
disorganised thinking and
memory impairment) No
Yes 
Is the patient
disorientated (i.e. lacking
awareness, being
mistaken about time,
place or person)
No Yes 
Is the patient agitated (i.e.
fearful affect, frequent
movements and anxious)
No Yes 
3. Vision Does the patient require Yes to any = 1
eyeglasses continually?
 No Yes 
Does the patient report
blurred vision ?
No Yes 
Does the patient have
glaucoma, cataracts or
macular degeneration?
No Yes 
4. Toileting Are there any alterations Yes = 2
in urination (i.e.
frequency urgency,
incontinence, nocturia) ?
No Yes 
5. Transfer score Independent 0 Add transfer score
(TS) [means from use of aids to be 1 (TS) and mobility
bed to chair and independent is 2 score (MS)
back] allowed 3 If value total
Minor help, between 0-2 then
one person easily score = 0
or needs If values total
supervision for between 3-6 then
safety score = 7
Major help –
one strong skilled
helper or two
normal people;
physically can sit
Unable no
sitting balance;
mechanical lift
6. Mobility score (MS)  0
 1
 2
 3
 Walks with help of
one person (verbal or
physical)





Action total score Total =
(As validated tool patient at risk if
total score ≥9)

THE SCALE FALL SYDNEY

SKALA RESIKO JATUH ONTARIO MODIFIED STRATIFY - SYDNEY SCORING

( GERIATRI )
No Parameter Skrining Jawaban Keterangan Nilai
1. Riwayat Jatuh Apakah pasien datang keRS Ya / tidak Salah satu jawaban
karena jatuh? ya = 6
Jika tidak, apakah pasien Ya / Tidak
mengalami jatuhdalam 2 bulan
terakhir ini ?
2. Status Mental Apakah pasien delirium ? Ya / Tidak Salah satu jawaban
(Tidak dapat membuat ya = 14
keputusan, pola pikir tidak
terorganisir, ganguan daya ingat
) Ya / Tidak
Apakah pasien disorientasi ?
(salah menyebutkan waktu,
tempat atau orang ) Ya / Tidak
Apakah pasien mengalami
agitasi ? (ketakutan, gelisah,
dan cemas)
3. Penglihatan Apakah pasien memakai Ya / Tidak Salah satu jawaban
kacamata ? ya = 1
Apakah pasien mengeluh Ya / Tidak
adanya penglihatan buram ?
Apakah pasien mempunyai Ya / Tidak
glaukoma ?Katarak /
degenerasi makula ?
4. Kebiasaan Berkemih Apakah terdapat perubahan Ya / Tidak Salah satu jawaban
perilaku berkemih? ( frekuensi, ya = 2
urgensi, inkontinensia,
nokturia)
5. Transfer ( dari tempat Mandiri ( boleh memakai alat 0 Jumlah nilai transfer
tidur ke kursi dan bantu jalan ) dan mobilitas jika
kembali lagi ketempat Memerlukan sedikit bantuan ( 1 1 nilai total 0 – 3
tidur ) orang ) / dalam pengawasan maka scor = 0
Memerlukan bantuan yang 2 Jika nilai total 4 – 6,
nyata ( 2 orang ) maka skor = 7
Tidak dapat duduk dengan 3
 seimbang, perlu bantuan total
6. Mobilitas Mandiri ( boleh memakai alat 0
bantu jalan ) 1
Berjalan dengan bantuan 1 2
orang ( verbal / fisik ) 3
Menggunakan kursi roda

Imobilisasi

Keterangan skor :
0-5 = resiko rendah
6-16 = resiko sedang
17-30 = resiko tinggi

CONCLUSION

1. The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s
likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and
easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. It
consists of six variables that are quick and easy to score, and it has been shown to
have predictive validity and interrater reliability
2. Humpty Dumpty Scale This study is an assessment of the risk of falling for the kids.
This study contains some items used to assess the risk of falling of the patient i.e. age,
gender, diagnosis, disorders, cognitive factors environment, response to surgery,
sedation, anesthesia, and as well as the use of drugs (Rodriguez, et al., 2009). The
level of Humpty Dumpty falls risk based on Scale partitioned into two 7-11 for a low
risk score and score ≥ 12 for the higher risk.

3. The Sydney Scoring is another name of Ontario Modified Stratify. This study is the
adaptation of the STRATIFY in the setting in Australia Hospital. Sydney The score is
used to assess the risk of falls in patients old age (elderly).

REFERENCE

1. Elizabeth Murray,jos vess, and barbara J. Edlund (Implementing a Pediatric Fall

Prevention Policy and Program)

2. Nursing Standar (2014) london vol.30 ,iss,48 (July 27, 2016) ;53
3. Peraturan Menteri Kesehatan Nomor 1691/Menkes/Per/VII/2011 tentang Keselamatan
Pasien Rumah Sakit

4. KKP-PERSI. 2008. Hand out Workshop Patient Safety. Bandung: KKP-PERSI.

5. Kartika, T. 2008. Keselamatan dan Keamanan. Makalah

6. American Association for the Advancement of Science et al. 1999. Proceedings of

Enhancing Patient Safety and Reducing Errors ini Health Care. Illinois: National
Patient Safety Foundation