Fall Risk Assessment: Morse Scale,

Humpty Dumpty, and Sydney

Arranged by:
Muhammad Fatih Ikhsan
(P1337420619067)
Elgariza Saraning Prasasti
(P1337420619023)
Tyastiani Harya Prabawati
(P1337420619087)
Definition of a Fall Patient

A fall patient is a patient who accidentally falls on the floor

with or without injury afterwards (Agency for Healthcare
Research and Quality).

According to the American Nursing Association or ANA (2009),

a fall patient is a condition where the patient falls directly on
the floor or overwrites something (equipment) on the floor that
occurs accidentally whether that causes injury or not and
occurs in the treatment room.
 Causes the patient to fall

Intrinsic risk factors

old age, history previous falls, muscle weakness,
balance problems, reduced vision, postural
hypotension, chronic medical conditions such as
arthritis, diabetes, stroke, Parkinson's, incontinence,
and dementia, as well as the patient's anxiety or fear of
falling incidents.
Extrinsic risk factors
lack of handrails on stairs, inaccurate design of stairs, lack of
handrails in bathrooms, lighting that is too dim or too glare, the
presence of objects that could potentially hinder or cause tripping,
slippery surface or floor conditions and unevenness, use of drugs,
and use of walking aids that are not right.
Langkah-langkah pencegahan kejadian pasien jatuh menurut
Hempel, et al., (2013) :

Memberikan Memberikan edukasi

Melakukan Memberikan
penanda kepada pasien dan
pengkajian risiko penanda ke
bagipasien
pasien
keluarga terkait risiko
jatuh denganresiko
dengan risiko jatuh
jatuh
jatuh

Melakukan evaluasi Memasang alarm di

Pemantauan keliling
post-fall bed-exit
 Fall risk assessment is a stage in patient safety services.
Patients will be assessed since entering the hospital. Fall
Risk Assessment include :

• Monitor patients since admission

• Monitor closely on patients at high risk
• Involve the patient or family in efforts to prevent
falling risks
• Reports of falling patient events
Fall Risk Assessment

1) Morse Fall Scale

2) Humpty Dumpty Scale
3) Sydney Scoring
Morse Fall Scale
Skala Sydney scoring
 The Sign

The level of falling risk from a

fall risk assessment is divided
into high, medium and low
risk. For patients with a high
risk put a falling risk sign on
a patient's bed
For patients with a falling risk will also be given a yellow
bracelet as a marker
Any Question ?