ICU Humpty Dumpty Guidelines - LearnLINKS

Who in the ICU area needs a Fall Assessment
Humpty Dumpty (Fall Assessment) ICU Guideline
For all patients older than 6 months in pediatric IICU or acute care-
Exclusions:
NOTE: requirement is based on patient status not on unit location (i.e. patient physically
located in ICU but receiving IICU level of care needs a fall assessment)
ICU patients may be assessed based on nurse’s discretion
All neonatal patients in neonatal units
All maternity patients (use appropriate adult scale)
All ICU patients who are receiving ICU level of care**
o ** ICU RNs can determine if patient is at risk and perform the Fall Assessment as
appropriate
Review the reference text in LINKS for more information/ policy.
How did I get an order for a Fall Assessment when my patient does not meet the criteria
Another staff member completed the iView Humpty Dumpty Fall assessment and the score
triggered the order. NOTE: ensure your patient does not meet the criteria for a Fall
Assessment before you remove the order.
CNE. 070111

How do I remove an order for a Fall Assessment when my patient does not require a Fall Assessment
1. Cancel the ‘Implement the High Risk Fall Standard Protocol Order’.
2. Complete the ‘D/C Implement High Risk Fall Standard Protocol’ order.
CNE. 070111