Development of Pressure Ulcer Management and Fall Prevention Protocol

Youngshin Song; Keumok Ban; Hye Young Kim; Sun Ae Kim; Seyeon Park; Myoungjin Kwon

doi:10.7739/jkafn.2023.30.3.391

J Korean Acad Fundam Nurs > Volume 30(3); 2023 > Article

Song, Ban, Kim, Kim, Park, and Kwon: Development of Pressure Ulcer Management and Fall Prevention Protocol

Original Article

J Korean Acad Fundam Nurs 2023; 30(3): 391-403.

Published online: August 31, 2023

DOI: https://doi.org/10.7739/jkafn.2023.30.3.391

Development of Pressure Ulcer Management and Fall Prevention Protocol

Youngshin Song¹⁾

, Keumok Ban²⁾

, Hye Young Kim³⁾

, Sun Ae Kim⁴⁾

, Seyeon Park⁵⁾

, Myoungjin Kwon^6),

¹⁾Professor, College of Nursing, Chungnam National University, Daejeon, Korea

²⁾Associate Professor, Department of Nursing, Chungcheong University, Cheongju, Korea

³⁾Professor, College of Nursing. Research Institute of Nursing Science, Jeonbuk National University, Jeonju, Korea

⁴⁾Associate Professor, Department of Nursing, Korea National University of Transportation, Chungbuk, Korea

⁵⁾Assistant Professor, College of Nursing, Chungnam National University, Daejeon, Korea

⁶⁾Associate Professor, Department of Nursing, Daejeon University, Daejeon, Korea

Corresponding author: Department of Nursing, Daejeon University 62 Daehak-ro, Dong-gu, Daejeon 34520, Korea Tel: +82-42-280-2665, Fax: +82-42-280-2785, E-mail: mjkwon@dju.kr

*This research was supported by a grant from Korean Academy of Fundamentals of Nursing (2022).

Received June 9, 2023 Revised July 21, 2023 Accepted August 18, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study developed a protocol to assess the core nursing skills of pressure ulcer management and fall prevention for nursing students.

Methods

Protocol development consisted of a preliminary investigation of the protocol for pressure ulcer management and fall prevention nursing (step 1), confirmation of the protocol criteria (step 2), development and confirmation of the final protocol (step 3), and development of nursing situations to apply the developed protocol (step 4). The validity of the protocol was measured using the content validity index.

Results

The pressure ulcer management and fall prevention nursing protocol we developed consisted of 23 procedures. The guidelines of KABONE (2021) were used to set the achievement goals and difficulty, corresponding to “low” for the achievement goal of evaluating and recording the risk factors. The protocol's content validity was good, and the developed scenarios were relevant.

Conclusion

Nursing practice is critical for nursing students to provide high-quality care in clinical settings. Therefore, it is essential to assess the core nursing skills that nursing students learn and acquire during their student years. The protocol developed in this study can be used to improve nursing education, particularly in the development of core nursing skills.

Key words: Accidental falls, Clinical protocols, Nursing students, Pressure ulcer

INTRODUCTION

Practical education that improves nurses’ practical skills and competencies for patient care is essential in nursing curricula. To improve the quality of practical education, the Korean Accreditation Board of Nursing Education (KABONE) designated 18 core nursing skills to ensure the core clinical competencies of professional nurses and to teach these competencies in practical subjects in universities [1,2].

Most universities have developed and evaluated nursing students’ competencies using the protocol suggested by KABONE since 2012 the core nursing skills. Accreditation for nursing education was reorganized into a 4th Cycle in 2021, named “core nursing skills,” and 18 revised core nursing skills were introduced to develop and assess nurses’ competency utilizing achievement goals and difficulty without specific protocols [1]. Of these, since pressure ulcer management and fall prevention are designated as new core nursing skills, there are no protocol, making it difficult to achieve student achievement goals. Therefore, it is necessary to develop a new protocol.

Practical education for pressure ulcer management and fall prevention is mainly done in the students’ third and fourth years, and begins in the second-year in basic nursing courses at many universities. To ensure that professional nurses have essential nursing competencies most nursing departments manage core nursing skills in stages until graduation, and KABONE checks them [2]. In these stages, practical education in basic nursing modules aims to teach students to perform simple skilloriented protocols without requiring clinical judgment or presenting them with complicated situations [3]. Pressure ulcer management and fall prevention are important in nursing education as they are core nursing skills that nurses must have and are areas that require skilled nursing provision. These two as-pects are health concerns that should be monitored from the beginning of hospitalization, and the abilities to mon-itor the environment and identify the risk factors early are basic competencies required of all nurses [4].

Pressure ulcers are a type of local injury occurring due to constant pressure or frequent friction on the skin over bony prominences or underlying tissue [5]. Assessing risk factors for pressure ulcers and nursing interventions minimizing pressure or friction are required to prevent pressure ulcers. Risk factors for pressure ulcers are friction, shear force, limitation of activity and mobility, skin condition, blood circulation, nutrition, moisture, body tem-perature, age, low pain sensitivity, general condition, mental status, history of pressure ulcers, and blood levels (serum hemoglobin and serum albumin). They are monitored using standardized tools [6-8]. The Braden Scale is a tool for assessing the risk of pressure ulcers, and it consists of six items and it evaluates the risk by providing the cut-off value [9]. In previous studies conducted with scoping review, about 70% of the review studies used the Braden Scale as a pressure ulcer evaluation tool, which is the most widely used tool [10].

Falls are a frequently reported safety accident among hospitalized patients during case monitoring, and they require various nursing interventions that depend on the patient's circumstances and the hospital environment [11]. The Morse Fall Scale (MFS), used to assess risk factors for falls, consists of six items-fall history, secondary diagnosis, ambulatory aid, intravenous therapy/heparin lock, gait/transferring, and cognition/mental status-and it is a valid tool that provides the cut-off value [12]. Moreover, the MFS is the most widely used tool for measuring fall risk factors [13].

Protocol development helps us develop repetitive and systematic education and apply protocols to practical education based on the developed guidelines. It is utilized in various learning methods for practical education. Several studies have reported on protocols used in various practical education methods such as simulation education, web-based learning, and video recording education, which were implemented to improve students’ knowledge, per-formance, and satisfaction, thereby increasing learning motivation [3,14-16].

Core Nursing Skill No. 17, pressure ulcer management and fall is a newly established item with a difficulty level of ‘ low’. Therefore, rather than complicated and difficult nursing techniques, ‘ risk assessment using tools’ was considered first. This study improves nursing students’ competencies and the quality of future practical education by developing a protocol for pressure ulcer management and fall prevention for nursing students.

1. Literature Review

1) Assessment tool for risk of pressure ulcers

As the development of pressure ulcers increases patients’ medical expenses [17] and their mortality rate [18], adequate nursing intervention should be performed be-fore pressure ulcers develop. Therefore, it is vital to assess the risk factors for developing pressure ulcers using a reliable assessment tool and take preventive measures.

Currently, the most commonly used risk assessment tool for pressure ulcers is the Braden Scale, which consists of six items: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Excluding friction and shear, which are assessed on a 3-point scale, the remaining 5 items are assessed on a 4-point scale, meaning the scale ranges from a minimum of 6 points to a maximum of 23 points. The lower the score, the higher the risk of pressure ulcers.

The Norton Scale, a risk assessment tool for pressure ulcers developed in 1962, earlier than the Braden Scale, was used to determine the risk factors for pressure ulcers in hospitalized older adult patients [19]. The scale's risk factors are divided into five domains: physical condition, mental condition, activity, mobility, and incontinence. The total score is 20 points, and participants rate each domain from a minimum of 1 to a maximum of 4 points; the lower the score, the higher the risk factor. In 1987, it was pro-posed that the boundary be raised to 16 points to reflect changes such as a medication factor [20]. The Norton Scale was validated mainly based on nurses’ assessments of older adult patients (aged 60 or older), and the scale's reliability and validity were supported.

The Gosnell Scale is a modified and supplemented tool that replaced Norton Scale's item “physical condition,” which was considered unclear, with nutrition condition. It evaluates mental condition on a 5-point scale, activity, mobility, and incontinence on a 4-point scale, and nutrition on a 3-point scale, ranging from a minimum score of 5 to a maximum of 20. The higher the score, the higher the possi-bility of developing a pressure ulcer [21].

In addition, the Waterlow Scale, developed in the U.K. in 1985, included special risk factors such as trauma, sur-gery, and neurological deficit and was revised in 2005 [22]. It comprises 11 detailed assessment factors, including weight and height, skin condition, sex, age, malnutrition screening, continence, mobility; and special risk factors, including tissue malnutrition, neurological deficit, major sur-gery or trauma, and medication. The minimum is 2 points, and a total score of 10 or higher is considered as being at risk for developing pressure ulcers, 15 or higher as being at high risk, and 20 or higher as being at very high risk.

Various tools are used to assess the risk factors of pressure ulcers, and considering the predictive validity of the tools, the Waterlow Scale can be considered regarding crit-ically ill surgical patients and when aiming to understand the patient's condition and progress simultaneously. How-ever, the Braden Scale has the advantage of clinical con-venience as a simple and widely used assessment tool [23].

2) Assessment tool for risk of falls

Falls are a safety accident that occurs frequently for older adults and can lead to death in extreme cases. Hence, as in the case of pressure ulcers, prevention is the most crucial intervention. As a first step to selecting high-risk fall groups and providing them with necessary nursing interventions, tools are required to assess the degree of fall risk.

The most commonly used assessment tool for the risk of falls among general adult patients is the MFS [13], which evaluates six detailed items: fall history, secondary diagnosis, use of ambulatory aid, intravenous injection/heparin cap, gait disorders, and cognitive ability [24]. It is evaluated from a minimum score of 0 to a maximum of 125. The higher the score, the higher the degree of fall risk. In particular, because more than 50 points classify one as in a high-risk group, the level of intervention varies depending on each degree of risk. In a previous study in South Korea, the negative predictive value, the percentage of patients expected not to fall in a tool according to the boundary score that did not actually fall, was evaluated as 91.4% [25], thus verifying the tool's usefulness.

The Johns Hopkins Hospital Fall Risk Assessment Tool [25], developed in 2005, is an assessment tool that evaluates the risk of falls from evidence-based activities for fall prevention activities at the Johns Hopkins Hospital [26]. The tool was supplemented in 2007. It consists of eight detailed items regarding age, history of falling, bowel and urine secretion, medication, patient care equipment, mobility, and cognition, and it is evaluated from a minimum score of 0 to a maximum of 35. A score of 6 to 13 is classified as moderate risk, and that exceeding 13 is classified as high risk. A study evaluating the tool's validity in South Korea found the scale's sensitivity to be at 69.0%, specific-ity at 60.0%, and negative predictive value at 88.6% at the boundary score of 12 points [24].

As the older adult population continuously increases, it is expected that tools for assessing the fall risk factors of patients will be developed and evaluated consistently. The MFS is considered and used as the most reliable fall risk factor assessment tool in clinical practice [27].

METHODS

1. Study Design

This methodological study was performed to develop a protocol for pressure ulcer management and fall prevention by applying the literature review and the 4th Cycle guidelines of KABONE.

2. Study Period

This study was conducted from August 2022 to Decem-ber 2022.

3. Protocol Development Process

Protocol development was performed through four steps as follows. Step 1-preliminary investigation; Step 2-confirmation of protocol criteria; Step 3-development of the final protocol; and Step 4-development of nursing situations to apply the developed protocol (Table 1).

Table 1.

Protocol Development Process

Step	Contents
1. Preliminary investigation	Previous research or literature review of professional organizations
2. Suggestion of criterion for protocol	Establish criteria (guideline, achievement level, etc.) for pressure ulcer management and fall prevention protocol application
3. Protocol development	Final protocol development
4. Nursing situation development	Nursing situation and pressure ulcer and fall risk checklist development for protocol application

In Step 1, data from previous research or professional organizations were reviewed. Data search was conducted on Google, Riss4u, and PubMed, Hospital Nurses Association, Medical Institution Accreditation Evaluation Institute and the search terms were ‘pressure ulcer’, ‘fall risk’, ‘pressure ulcer assessment tool’, and ‘fall risk assessment tool’. The criteria to apply the protocol for pressure ulcer management and fall prevention (guidelines, achievement levels, and difficulty) were determined in Step 2. In Step 3, the final protocol was developed, and nursing situations to apply the protocol and a checklist of pressure ulcer and fall risks were developed in Step 4.

In Steps 3 and 4, the Content Validity Index (CVI) was conducted. Three experts evaluated the validity: a nurse with at least 25 years of nursing experience and teaching experience, and two nursing professors who teach fundamental of nursing. In addition, to apply the protocol, nursing scenarios reflecting actual clinical scenarios were developed, the developed protocol was implemented, and the three experts evaluated the relevance of the protocol and scenarios.

4. Data Analysis Method

CVI was used to determine the validity of the preliminary protocol. Protocol items were measured on a 4-point Likert scale (1 point for strongly unrelated, 2 points for unrelated, 3 points for related, and 4 points for strongly related), and the percentage of 3 or 4 points was calculated out of 1∼4 points and were evaluated as valid if they were more than.80 [28].

RESULTS

Based on previous studies, literature review, and the core nursing skill guidelines of KABONE, a protocol was developed applying the Braden Scale in pressure ulcer risk assessment for pressure ulcer prevention and utilizing the MFS for fall prevention (Table 2).

Table 2.

Pressure Ulcer Management and Fall Prevention Protocol

No.	Steps	Fully performed (2)	Partially performed (1)	Not performed (0)	Note
1	Perform hand hygiene with soap and water.
2	Gather the necessary supplies
3	Take the supplies to the patient and introduce yourself.
4	Perform hand hygiene with sanitizer.
5	Ask for the patient's name to confirm their identity, and confirm their name and registration number on the arm band with that on the patient list (or prescription).
Pressure ulcer risk assessment
6	Check sensory perception. (Ability to respond meaningfully to pressure-related discomfort).
7	Check moist. (Degree to which skin is exposed to moisture)
8	Check activity. (Degree of physical activity)
9	Check mobility. (Ability to change and control body position)
10	Check nutrition. (Usual food intake pattern)
11	Check for friction and shear caused by the duvet on the bed.
12	Respond to patient's questions and conduct education for pressure ulcer prevention.
Fall risk assessment
13	Check whether the patient has experienced a fall.
14	Check whether there is a secondary diagnosis.
15	Check for assistance when walking
16	Check intravenous fluid therapy or heparin lock.
17	Check the gait.
18	Check consciousness information.
19	Respond to patient's questions and conduct education for fall prevention.(If necessary) A fall warning notice is provided and bracelets are worn.
20	Check the patient for any discomfort.
21	Organize used items.
22	Perform hand hygiene with soap and water.
23	Document your activity. 1) Assessment content (pressure ulcer risk and fall risk assessment score) 2) Performance contents 3) Education contents
Total

Achievement goals and difficulty applied the 4th cycle guidelines of KABONE (2021), and achievement goals were set to evaluate and record the risk factors corresponding to “low” (Appendix 1). The Braden Scale and MFS were added in Appendix 2 and Appendix 3.

As a result of the first CVI of the preliminary protocol, item 1 of the protocol, ‘wash your hands with hand sanitizer’, was modified to ‘hand hygiene with soap and water’, the same as other core nursing skills. The CVI of the protocol item measured again after the revision of item 1 was improved from 0.8 to 1, and the validity was improved, and the protocol was confirmed. The protocol for pressure ulcer management and fall prevention consisted of 23 procedures, and the scoring system comprised 46 points, with 2 points for completely performed; 1 for partially performed; and 0 for not performed (Table 2, Appendix 4). In addition, to evaluate the protocol for pressure ulcer management and fall prevention, a checklist for recording pressure ulcer management and fall prevention was developed, and the appraisee was allowed to record risk factors directly in the simulated nursing situations (Table 3, Appendix 5).

Table 3.

Nursing Scenarios related to Pressure Ulcer Management and Fall Prevention

Kim, a 70-year-old woman, is on her third day after being hospitalized through an outpatient clinic due to suspected pneumonia. She is conscious and walks with a cane with right hemiparesis, and a fall caution sign is attached to her bed. She is receiving nursing care and education for prevention of pressure ulcer and falls using a checklist during regular visits by a nurse in charge every day.

The nursing scenarios provided were presented to experts to evaluate their validity and the scenarios were found to be related to the protocol according to experts’ assessments. The Nursing scenario also showed good validity with a CVI of 1.

DISCUSSION

In the 4th cycle of accreditation for nursing education, “pressure ulcer management and fall prevention” were designated as new core nursing skills based on a job analysis of new nurses working in clinical practice after graduation [29]. Thus, this study developed a protocol for “pressure ulcer management and fall prevention” to improve nursing students’ core nursing skills and the quality of nursing practice.

The protocol was developed according to the difficulty level “low” recommended by “pressure ulcer management and fall prevention” presented by KABONE [1]. Based on the Norton Scale and Braden Scale, which are the most commonly used tools for pressure ulcer management [30], a protocol was developed according to the principle of occurrence of pressure ulcers, stages of pressure ulcers, and preventative nursing for pressure ulcers, which are the goals presented by KABONE. Items 6 (check senses) and 7 (check the degree of skin exposure to moisture) are related to skin function, which is prior knowledge presented by KABONE. Items 8 (check the level of activity such as physical activity and walking), 9 (check the ability to change and adjust body position), and 11 (check friction and shear due to bedclothes on a bed) were developed as those related to the principle of pressure ulcer occurrence and prior knowledge of the pressure ulcer stages. Items 10 (check nutrition such as food intake) and 12 (respond to the questions of the subject and conduct education for pressure ulcer prevention) are related to preventative nursing for pressure ulcers.

This protocol was revised and supplemented in the five domains of the Norton Scale and six domains of the Braden Scale, and nutrition was included for pressure ulcer management even though the two tools do not overlap regarding this factor. Because nutrition plays an important role in the prevention and treatment of bedsores. The exact causal relationship between various nutrients and bedsores is not yet clear, but sufficient nutrition is believed to help prevent and heal wounds in patients vulnerable to bedsores, EPUAP/NPIAP/PPPIA's 2019 International Guidelines the department sees it as an independent risk factor for the occurrence of pressure ulcers [31].

The pressure ulcer is divided into several stages according to its condition and severity, and pressure ulcer management should be applied separately accordingly [32]. The pressure ulcer healing process should be continuously and systematically monitored and immediate re-evaluation is required. Therefore, objective tools for assessment are important, and therefore, the comprehensive pressure ulcer management tools developed in this study are expected to be useful.

Fall accidents in hospitals often lead to legal problems, so patient and guardian education for fall prevention is conducted in various ways. The fall prevention tool developed in this study was modified through the advice of a group of experts who suggested revising and supplementing some items, and was developed to evaluate the risk by selecting the items associated with the highest risk of falls.

Protocol development for fall prevention was conducted based on MFS and Bobath Memorial Hospital Fall Risk Assessment Scale. Items 13 (check past experiences of falling), 14 (check the secondary diagnosis), 15 (check the ambulatory aid), 16 (check the intravenous therapy/heparin lock), 17 (check the gait), and 18 (check the cognition information) are associated with the fall risk factors and assessment method, which are prior knowledge presented by KABONE. Item 19 (respond to patients’ questions and conduct education for fall prevention, and, if necessary, provide a fall warning notice and wear a bracelet) was included in the protocol as fall prevention.

This protocol was developed focusing on what nursing students need to assess for fall prevention, excluding over-lapping in eight domains of the Bobath Memorial Hospital Fall Risk Assessment Scale and six domains of the MFS. As conventional tools scored each from 0∼3 or 0∼30, it may have been difficult for students to calculate or determine easily, but this developed protocol allows them to respond to items through either ‘ yes’ or ‘ no.’ Therefore, it is in-tuitive and is thought to support accurate clinical judgment.

Experts evaluated the developed scenario and protocol of “pressure ulcer management and fall prevention” as suitable for first-class nursing students. It also contains the latest knowledge and key nursing skills and provides specific evaluation criteria for instructors to objectively evaluate students’ skill levels. “Pressure ulcer management and fall prevention” is safety nursing care, which is crucial in improving the quality of care. Moreover, as awareness of patient safety increases, items related to pressure ulcer prevention and management are also included in the medical institution assessment in South Korea [33]. Therefore, this protocol will make it possible to provide standardized nursing care for “pressure ulcer management and fall prevention” not only for nursing students but also for clinical nurses, thus further contributing to improve the quality of care.

CONCLUSION

Pressure ulcers and falls increase the risk of infection, can cause disability, and reduce patients’ quality of life, thus burdening patients and their families through extended hospital stays and increased medical costs. It is necessary to improve patients’ health and quality of life by preventing pressure ulcers and falls and by providing ap-propriate care and treatment when these occur. Utilizing assessment tools with proven validity and reliability to evaluate the risk of pressure ulcers and falls is critical in preventing pressure ulcers and falls and improving nurses’ knowledge of these issues. The Braden Scale is the most widely used assessment tool for evaluating the risk of pressure ulcers. The MFS is the most widely used assessment tool for evaluating fall risk. Various tools with proven validity and reliability are necessary for effective prevention and nursing care for pressure ulcers and falls.

The protocol developed in this study was systematic and standardized as an evidence-based protocol through literature. In addition, the validity is verified and applicable to education and evaluation. Despite this significance, this protocol lacks cumulative application performance. Therefore, continuous application and feedback of the protocol are required in the future. In this study, the Braden Scale and the Morse fall scale were used. It is also necessary to use other tools that have secured validity and reliability in the future. And in this study, one scenario was presented. Further development of various scenarios and protocols is required.

Notes

CONFLICTS OF INTEREST

Youngshin Song has been president of the Korean Academy of Fundamentals of Nursing since January 2022, and her term will continue until the end of 2023. Hye Young Kim has been editor-in-chief of the Journal of Korean Academy of Fundamentals of Nursing since January 2022. All of them were not involved in the review process of this manuscript. Otherwise, there was no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - Song Y, Ban K, Kim HY, Kim SA, Park S, & Kwon M; Data collection - Song Y, Ban K, & Kim HY; Data analysis & Interpretation - Kim SA, Park S, & Kwon M; Drafting & Revision of the manuscript - Song Y, Ban K, Kim HY, Kim SA, Park S, & Kwon M.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Appendices

Appendix 1.

욕창관리 및 낙상예방간호 간호상황과 성취목표, 선행지식, 준비물품.＜난이도: 하＞

1. 시나리오 요약	70세 김예방 (여), 폐렴의심 증상으로 외래를 통해 입원하여 3일째 되는 날
	과거력: 10년 전 고혈압진단, 8년 전 뇌졸중으로 오른쪽 편마비, 그 외 만성질환은 없음, 과거 낙상 경험 없음
	현재상태: 오른쪽 편마비로 지팡이를 짚고 보행가능, 의식명료, 의사소통 문제없음
	복용약물: 항고혈압, 현재 산소요법 중 (5L via nasal prong)
2. 성취목표	욕창관리 및 낙상예방간호에 필요한 물품을 준비할 수 있다.
	욕창관리 및 낙상예방간호의 목적과 절차를 설명할 수 있다.
	욕창 및 낙상의 위험요인을 사정할 수 있다.
	욕창 및 낙상 위험요인에 따른 예방간호를 수행할 수 있다.
	욕창예방간호 및 낙상예방간호의 수행결과를 기록할 수 있다.
3. 선행지식	피부의 기능과 해부생리
	욕창발생의 원리와 욕창단계
	낙상의 위험요인과 사정 방법
	드레싱의 종류와 사용방법
	신체보호대의 종류와 사용방법
	낙상예방간호 및 욕창예방간호
4. 준비물품	[공통]
	침대 (보조난간), 대상자 이름표
	손소독제
	간호기록지
	[욕창관리]	[낙상예방간호]
	욕창모형 (필요 시)	낙상위험도 사정도구 (체크리스트)
	욕창위험도 사정도구 (체크리스트)	낙상주의 표지판과 안내문
	펜라이트 (필요 시)	낙상주의 팔찌
	욕창예방용 보조물품 (공기침요, 베개 등)	낙상예방 교육지침
	욕창예방 교육지침	신체 보호대 (필요 시)

Appendix 2.

욕창위험 체크리스트 양식

욕창위험 체크리스트 양식
등록번호		환자 성명
성별/나이		진단명/수술명
욕창 위험도 체크리스트(Braden Scale)
영역		하위 영역	점수	평가 일시
감각지각 (압력과 관련된 불편함에 대하여 반응하는 능력)	완전 제한	의식수준의 저하나 진정제 때문에 아픈 자극에 무반응(신음, 주춤하거나 쥐는 반응이 없음), 또는 대부분의 신체 표면에서 통증을 느끼는 능력이 제한됨	1
	매우 제한	통증자극에만 반응, 신음, 불안정음을 제외한 불편감에 대한 의사소통을 할 수 없음, 또는 신체의 1/2에서 통증이나 불편감을 느끼는 능력이 제한되는 감각장애	2
	약간 제한	언어지시에 반응하나 항상 체위변경에 대한 필요성이나 불편감에 대해 의사소통 할 수 없음, 사지 중 1-2부위에 불편감이나 통증을 느끼는 능력이 제한되는 부분적 감각장애	3
	제한없음	언어지시에 반응, 통증, 불편감에 대해 느끼고 말하는 능력이 제한되는 감각장애가 없음	4
피부습기 (피부가 습기에 노출된 정도)	항상 축축함	발한, 소변 등에 의해 피부가 항상 습한 상태를 유지, 환자를 움직일 때, 자세를 변경할 때마다 습기가 발견됨	1
	축축함	피부가 자주 습하지만 항상 습하지는 않음, 린넨은 근무교대 시 최소 한 번씩 교환해야 함	2
	가끔 축축함	피부가 가끔 습하여 하루에 대략 한 번 정도 린넨 교환이 요구됨	3
	거의 축축하지 않음	피부가 평소에 건조함, 린넨은 주기적인 간격으로 교환이 요구됨	4
	침대에만 있음	활동이 침대로 제한	1
활동상태 (신체활동 정도)	주로 앉아 있음	보행능력이 심하게 제한되거나 없는 상태, 자신의 체중을 견디지 못하거나 또는 의자나 휠체어가 필요	2
	가끔 보행함	도움을 받거나 하루 중 스스로 걷지만 매우 짧은 거리임, 대부분 침대나 의자에서 보냄	3
	자주 보행함	방 밖으로 최소 하루에 2번 이상 걸어다니고 방 안에서 깨어 있는 동안 최소 2시간에 한 번씩 걸어 다님	4
	완전 부동	도움 없이는 신체나 사지를 조금도 움직일 수 없음	1
가동성 (체위를 변경하고 조절하는 능력)	매우 제한	제한적으로 체위를 변경할 수 있어 자주 변경할 수 없거나 자유롭게 큰 변경은 불가능	2
	약간 제한	스스로 신체나 사지를 조금 움직이기는 하지만 자주 움직일 수 있음	3
	제한없음	도움 없이 모든 자세 변경을 자주 할 수 있음	4
영양섭취 (일상적인 음식섭취 양상)	매우 불량	전혀 식사를 다 하지 못함, 드물게는 제공한 음식의 1/3 이상 섭취, 하루에 단백질(고기, 유제품 등)은 2단위 이하만 섭취, 수분 섭취도 부족, 유동식을 추가하여 섭취하지 못함, 또는 5일 이상 금식/정맥요법이나 맑은 유동식 유지	1
	불량함	드물게 식사를 다 하며, 일반적으로 제공된 음식의 1/2 정도를 섭취, 하루에 고기나 유제품으로 3단위 섭취, 가끔 식이보충제 섭취, 또는 최소량의 유동식이나 경관식 공급받음	2
	적절함	대부분 식사의 1/2 이상 섭취, 매일 단백질의 4단위를 섭취, 가끔 식사를 거부하나 만일 제공될 경우 식이보충제 섭취, 또는 경관식이나 완전비경구 영양요법을 받아 대부분의 영양요구를 거의 충족함	3
	우수함	대부분 매일 식사, 결코 식사를 거절하지 않음, 대부분 고기와 유제품으로 4단위 이상을 섭취, 가끔 간식도 섭취하며 보충제 필요 없음	4
	문제가 있음	움직이는 데 중등도에서 최대의 도움이 필요함, 홑이불에서 미끄러지지 않으면서 들어올리기 불가능함, 종종 침대나 의자에서 미끄러져 전적인 도움이 필요, 경련, 구축, 들썩거림 등은 대부분 지속적인 마찰을 일으킴	1
피부마찰과 쓸림	잠재적 문제	미약하게 움직이거나 약간의 도움이 필요함, 움직이는 동안 피부가 시트, 의자, 억제대, 다른 기구 등과 마찰하며 약간 미끄러짐, 의자나 침대에서 비교적 좋은 자세를 유지하지만 가끔 미끄러져 내려감	2
	문제없음	침대나 의자에서 스스로 움직이며, 움직이는 동안 완전하게 들어 올릴 수 있도록 충분한 근육의 힘을 가짐	3
		총점
		*결과해석: 점수가 낮을수록 욕창 위험이 높음을 의미저위험군: 15-18점, 중위험군: 13-14점, 고위험군: 10-12점, 초고위험군: 9점 이하

Appendix 3.

낙상위험 체크리스트 양식

낙상위험 체크리스트 양식
등록번호	환자 성명
성별/ 나이	진단명/ 수술명
낙상위험도 체크리스트(Morse Fall Scale)
구분	척도	점수	평가일시
과거낙상경험(3개월 이내)	없음	0
과거낙상경험(3개월 이내)	있음	25
이차적인 진단	없음	0
이차적인 진단	있음	15
보행 보조(보조기구)	보조기 사용하지 않음/침상 안정/휠체어/사람이 도와줌	0
	목발/지팡이/보행기 사용	15
	보조기 이외에 주변 기물/기구를 잡고 보행	30
정맥수액요법/헤파린 록	없음	0
정맥수액요법/헤파린 록	있음	20
걸음걸이(보행/이동)	정상 보행(시선, 균형 보폭 유지/침상 안정/부동)	0
	균형 및 시선 유지되지만, 기력이 저하됨	10
	장애가 있음(사람이나 기구의 도움 없이는 걸을 수 없는 사람/시선 및 균형 유지 불가능/의족 착용/ 파킨슨 보행)	20
의식장애 (정신상태 및 이행도)	의식 명료하며 자신의 기능 수준에 대해 잘 알고 있음	0
	의식 명료하지 않거나 자신의 기능 수준을 과대평가하거나 잊어버림	15
	총점

*결과 해석

0∼24점: 저위험군, 낙상 위험성이 거의 없음(No risk)

25∼50점: 중위험군, 낙상 위험성이 낮음(Low risk)

51∼125점: 고위험군, 낙상 위험성이 높음(High risk)

(단 기준점은 의료기관, 시설의 종류에 따라 다르게 적용할 수 있음)

Appendix 4.

욕창관리와 낙상예방 프로토콜

번호	수행항목	완전 수행 (2)	부분 수행 (1)	미수행 (0)	비고
1	물과 비누로 손위생을 실시한다.
2	필요한 물품을 준비한다.
3	준비한 물품을 가지고 대상자에게 가서 간호사 자신을 소개한다.
4	손소독제로 손위생을 실시한다.
5	대상자의 이름을 개방형으로 질문하여 대상자를 확인하고, 입원팔찌와 환자리스트 (또는 처방지)를 대조하여 대상자 (이름, 등록번호)를 확인한다.
욕창위험도 평가
6	감각을 확인한다 (압력과 관련된 불편함에 대하여 반응하는 능력).
7	피부가 습기에 노출된 정도를 확인한다.
8	신체활동, 보행 등 활동 정도를 확인한다.
9	체위를 변경하고 조절하는 능력을 확인한다.
10	음식 섭취 등 영양을 확인한다.
11	침상 위 이불에 의한 마찰과 엇밀림을 확인한다.
12	욕창예방을 위한 대상자 질문에 대한 응답 및 교육을 실시한다.
낙상위험도 평가
13	낙상 경험 여부를 확인한다.
14	2차적 진단 유무를 확인한다.
15	보행 보조여부를 확인한다.
16	정맥수액요법이나 헤파린 록을 확인한다.
17	걸음걸이를 확인한다.
18	의식정보를 확인한다.
19	낙상예방을 위한 대상자 질문에 대한 응답 및 교육을 실시한다. (필요 시) 낙상주의 안내문을 제공하고 팔찌를 착용해준다.
20	대상자에게 불편감이 있는지 확인한다.
21	사용한 물품을 정리한다.
22	물과 비누로 손위생을 실시한다.
23	수행 결과를 간호기록지에 기록한다. 1) 사정내용 (욕창과 낙상위험도 평가점수) 2) 수행내용 3) 교육내용
합계

Appendix 5.

교수자용 간호상황 요약서

간호수행 지시서	다음 상황을 보고 체크리스트를 활용하여 대상자에게 욕창/낙상 위험도를 평가하고 필요한 예방간호를 시행하시오.
상황 요약	70세 김예방 (여), 폐렴의심 증상으로 외래를 통해 입원하여 3일째 되는 날로 의식이 명료하고 오른쪽 편마비로 지팡이보행을 하고 있으며 침상에 낙상주의 표지판이 붙어있다. 매일 담당간호사의 정기순회 시 체크리스트를 활용한 욕창과 낙상예방을 위한 간호와 교육을 받고 있다.
환자 역할	침상에서 산소요법을 받고 있고 담당간호사에게 욕창/낙상예방에 대한 평가와 교육을 받고 있다.
주증상	호흡곤란	진단명	폐렴
환자이름	김예방
환자특성	연령: 70세	성별: 여
	신장: 156cm	체중: 58kg
	-병색/표정/기분/목소리/자세/몸짓/외모/복장: 환자는 환자복을 입고 있고 산소요법 (5L)을 비강캐뉼라를 통해 투여받고 있으며 지팡이 보행을 하고 있으나 일상생활이 가능한 상태
	간호사에 대한 태도: 협조적이며 의료진에 대한 신뢰가 있음
전반적 정서	시작: 피곤해 함, 불안이나 우울 없음
	중간: 욕창/낙상예방 안내에 대해 질문함
	종료: 조용히 경청
관련 병력	환자가 말하는 주 호소: 특별한 호소 없음
	질병의 경과: 오른쪽 편마비가 있어 보행이 허약하나 일상생활은 모두 가능함
	과거병력: 고혈압, 뇌졸중/수술이나 사고는 없었음
	사회력: 오른쪽 편마비로 사회활동에 거부감 있음
	가족력/산과력: 친정아버지가 고혈압이 있었고 뇌졸중으로 사망
표준화 환자 주요질문	1. 욕창이 생기면 처음에 어떤 증상이 생기나요? 2. 욕창은 어떤 때 잘 생기나요?