Question

A 6-year-old male was riding his bicycle without a helmet and was struck by a car. He is hospitalized for a concussion and fractured arm. He is admitted to the pediatric unit after surgery where an open reduction internal fixation was performed to repair the fracture. The patient is having some confusion due to the concussion he sustained and keeps trying to get out of bed, unassisted. He is receiving morphine for pain management. 1. What is the patient's fall risk score using the Humpty Dumpty Scale? 2. Which fall safety risk should be implemented? 3. Identify three interventions that the nurse should implement for this patient?

Answer 1

1.According to humpty dumpty score

Medication(sedation)	2
Age:(3_7 year)	3
Gender (Male:1)	1
Diagnosis if Neurological	4
Cognition if not aware	3
Environmental factor if patient is in bed	2
Response to surgery sedation post operatively	3

The total score is 18

In Humpty Dumpty Score the minimum fall risk score is 7 and high fall risk if above 12.

The patient has a very high risk for fall

2.The safety protocol for high risk to be implemented here such as keeping patient near nurse station ,low level of bed ,assisting with mobilization, monitoring medication, etc.,

3The three intervention to be implemented by a nurse are

• Side rails of be up
• Parents with the child continuously
• Physical restraints if ordered by pediatrician and acceptance of parents