Risk Factors in the Development of Pressure Ulcers in an

Intensive Care Unit in Pontianak, Indonesia.

Suriadi, MSN,RN1, Hiromi Sanada, Ph.D, RN2, Junko Sugama, Ph.D, RN1, Brian
Thigpen, M.Ed3, Atsuko Kitagawa, Ph.D, RN2,
Sachiko Kinosita, MSN, RN1, Shizuko Murayama, MSN, RN1
Address:
1

Department of Clinical Nursing, Division of Health Sciences, Graduate School of Medical

Science, Kanazawa University, 5-11-80 Kodatsuno, Kanazawa 920-0942 Japan.

2

Department of Gerontological Nursing, Division of Health Sciences and Nursing, Graduate

School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033
Japan.
3

Consultant Education, Faculty of Education, University Tanjungpura Pontianak, Indonesia.

E-mail address in order:

Suriadi = suriadif@yahoo.com.au
Hiromi Sanada = hsanada-tky@umin.ac.jp
Junko Sugama= junkosgm@mhs.mp.kanazawa-u.ac.jp

Brian Thigpen = theguru822@yahoo.com

Atsuko Kitagawa= akbear-tky@umin.ac.jp
Sachiko Kinosita= s-kinokp156@nifty.ne.jp
Shizuka Murayama= shizuko-m@gamma.ocn.ne.jp

Tel/Fax:

Corresponding author.

Japan Tel.: + 81 76 265-2555; Fax: +81 76 234-4363

Abstract

This study was done to identify risk factors for pressure ulcers based on the Braden
Scale and other risk factors in an intensive care unit in Indonesia. The prospective
cohort design was conducted in this study. 105 patients participated and a pressure ulcer
developed in 35 patients. Risk factors identified for pressure ulcer development were
friction & shear, interface pressure, skin moisture, and smoking. The interface pressure
and skin moisture measurements have the additional advantage that they are quantitative
and objective. The results suggest that interface pressure measured by using a pressure
scanning aid and skin moisture measured by a moisture checker are adequate instrument
for prediction of pressure ulcers development.
Keywords: pressure ulcers, risk factor, prospective cohort, Braden Scale, intensive
care unit

Introduction
In Indonesia, the data collected from a 15-bed intensive care unit (ICU) at a
Pontianak public hospital (Pontianak City, West Kalimantan, formerly know as Borneo
Island) from January to June 1999, showed a pressure ulcer incident rate of 29%. This is
still exceptionally high the incident rate in ASIAN Countries which ranges from 2.1% to
31.3%1,2,3. Some reasons for the high incidence of pressure ulcers may be that there is no
evidence-based risk assessment scale used for prediction of pressure ulcers, and risk
factors for pressure ulcer development have not yet been identified in Indonesia.
Nurses only based on their clinical judgment to identify risk of pressure ulcers
development and prescribing nursing interventions to implement the strategy of care.
Therefore, the identification of specific risk factors for pressure ulcer development in
the ICU setting is important, so that nurses can assess risk factor and reduces the
incidence of pressure ulcers.
Some international studies were conducted to identify risk factors for pressure ulcer

development in ICU. These studies found that factors associated with pressure ulcer
occurrence were moisture, sensory perception, circulation, faecal incontinence, anemia,
length of stay, norepinephrine, coma / unresponsivness / paralysed & sedated,
cardiovascular instability, infection, age, patient status, skin condition and total Braden
score

4,5,6,7,8

. Although Braden Scale and others risk factors were investigated widely,

however the studies found inconsistency finding of risk factors for pressure ulcers
development. Some of reasons are possible different in setting, patients condition,
diseases, cultural, and climate in each hospital or country. The aim of this study was to
identify risk factors that are associated with the development of pressure ulcers in the
ICU setting in Indonesia. Moreover, the researcher attempted to scientifically prove
some of the Braden Scale factors such as interface pressure, skin moisture, iliac measure
that have not yet been proven in previous studies in ICU. For this purpose, the following
research question is formulated; which risk factors are associated with the presence of
pressure ulcers in the ICU setting in Indonesia.

Methods
Design
A prospective cohort design was used to identify risk factors for pressure ulcers
development in an intensive care unit in Indonesia, from February to July 2003.

Setting
The study was conducted in a 15-bed intensive care unit at St. Antonius, a public
hospital in Pontianak, an urban area in Indonesia. The hospital, at that time, had a bed
capacity of 300 beds.

Subjects

The following conditions applied to this study: Inclusion criteria: All patients were
required to be free of pressure ulcers at the beginning of the study. They were bedfast or
could not walk, admission to the intensive care unit at least 24 admitted before
enrollment in the study, expected length of stay at least 3 days (72 hours) after initial
data collection, and gave their informed consent. Exclusion criteria: Any patient who
was physically incapable of participating (difficult to identify the skin condition
everyday because patient could not be manipulated), or any patient who did not wish to
participate in this study was excluded. Withdrawal criteria: Any patient that wished to
withdraw from the study could do so at any time without giving a reason, or if a patient
developed a pressure ulcer, or died during the study, they were withdrawn.

The conceptual framework

The study was conceptualized according Braden and Bergstrom model of conceptual
schema which has been modified9. This model consists in two variables they are
dependent and independent variable. We determined in an independent two kind of type
variable they are qualitative and quantitative variable. From this model, the risk factors
associated with pressure ulcers are sensory perception, mobility, activity, interface
pressure, friction & shear, moisture, fecal incontinence, skin moisture, environmental
moisture, room temperature, room humidity, nutrition, albumin, hemoglobin, triceps
skinfold, iliac measure, age, diastolic pressure, systolic pressure, body temperature and
smoking (figure 1).
Dependent variable measurements
Pressure ulcers were identified and classified using (NPUAP)9. The definition of the
outcome (pressure ulcers) was made particularly clear to avoid bias. The skin condition
of each patient was assessed daily by primary researcher. To identify pressure ulcer

stage I, we determined that the skin is intact but shows a persistent pink or red area that
does not turn white when it is pressed with a finger. If the pressure ulcer appeared to be
stage I, it was examined and repeated 4 to 6 and 24 hours later to distinguish it from
transient reactive hyperemia. Skin assessment was included documentation of anatomic
location and stage.
Independent variables measurement
This study examined the independent variables that were expected to be positively
associated with pressure ulcers development.
1. Qualitative variables
1.a. The Braden Scale
The Braden Scale instrument, composed of six sub factors, was used to assess the
patients who were at risk of pressure ulcer development. They are sensory perception,
moisture, activity, mobility, nutrition and friction & shear.
1.b. Faecal incontinence
The fecal incontinence was considerate to contribute the moisture for sub-categorical
from Braden Scale. Previous study found that faecal incontinence was significant in
pressure ulcer development6. However, faecal incontinent has not been identified
adequately in an intensive care unit. Faecal incontinence was assessed by using
categorical yes and no.
2. Quantitative variables
2.a. Interface pressure.
Interface pressure was recorded using a pressure-scanning aid (Cello , Cape Co. Ltd.,
Japan). This instrument consists of three sensors filled with polymer foam, each in a fan
shape, 38 mm long, 35 mm wide and 1.5 mm thick.
2.b. Skin and environmental moisture.

Skin moisture was measured by using a moisture checker (MY707s, Scalar America,
Scalar Kabushiki Company, Japan). The interrater reliability for this instrument is
0.2%. Room humidity and temperature was measured using a humidity and
temperature-monitoring device (Hygrometer Sato Keiryoki Mfg. Co. Ltd., Japan). The
accuracy of these instruments are 0.1 0C and 5% (at 23 0C), respectively.
2.c. Nutritional condition.
To evaluate nutritional condition, the albumin and hemoglobin count in the blood was
measured using a blood-monitoring device (Photo Meter 4020, Boehringer Mannheim
Co., Germany). iliac measure, an iliac measuring device which is a circular plastic tool
9 cm in diameter, and 20g in weight (SS Seiyaku Co., Japan). The skin fold thickness at
the triceps was measured by skin fold calipers (Dainato Co. Ltd., Japan).
2.d. Body temperature and blood pressure.
Body temperature was measured using an electronic thermometer (C863 , Terumo
Medical Products Co. Ltd., Japan). The accuracy of this instrument is 0.1 0C. Blood
pressure was measured using a blood pressure monitoring device (MDE Escort Prism ,
Advance Medical System (M) Sdn. Bhd. Co. Malaysia).
2.e. Smoking.
We divided the patients into three categories: smoke more than 10 cigarettes per day,
smoke less than 10 cigarettes per day, and not currently smoking.

Procedures
The researcher selected the patients for this study within 24 hours after being
admitted to the intensive care unit. All demographic data was collected at the beginning
of the study. Three nurses practitioners in ICU with the same level were oriented and
trained to purposes and procedures of the study. Using the Braden scale, this study was

conducted to determine interater reliability. This analysis, calculated by Persons

product moment, was correlated ranged from r = 0.88 to 0.95. The Braden Scale
assessment was repeated three times per week. If a pressure ulcer was identified, the
researchers stopped their assessment and the patient was withdrawn from the study.
Interface pressure measurement was taken at the patients sacrum after the 24 hour
monitoring period had expired for a newly admitted patient to the intensive care unit.
Skin moisture, this procedure was conducted in the same manner as the interface
pressure. Room humidity and temperature measurement procedure was conducted 3
times daily. The bony prominence was measured at the iliac and triceps skin fold
measurement was taken by placing the instrument calipers over the midpoint of the skin
fold on the right side of the body for each patient. The patients nutritional status was
checked twice a week. This procedure was repeated three times during each assessment,
and the average value was used. Body temperature and blood pressure were conducted
three times daily. Smoking data was obtained from the patients medical records and/or
family. Then we also daily assessed the fecal incontinence status of all patients. Fecal
incontinence was assessed by researcher every day and reconfirmed on medical record..

Data analysis
Univariate statistics ( and t test) were used to identify which risk factors for
pressure ulcer development were statistically significant different between two groups
(pressure ulcer and no pressure ulcer). For patients who developed a pressure ulcer, the
Braden Scale values and other risk factors obtained in the last assessment before
pressure ulcer were used, and for patients who did not develop a pressure ulcer, their
mean score was obtained. To determine the correlation between variables data from the
Braden Scale sub factors and other risk factors, we used Pearson for continuous data

and Spearman correlation for ordinal data.

We did stepwise discriminant analysis to identify two groups, which were
differentiated by the risk factors. This method was conducted to determine variables
contributed the most to pressure ulcers development. In the analysis, we used the
statistical Package for Social Science (SPSS), version11.0 for data analysis.

Results
Total subjects admitted to the intensive care unit were 297 patients. 191 patients were
excluded from this study for various reasons; they had pressure ulcers when admitted,
were one-day care, able to ambulate, transferring, or incapable of participating. One
patient withdrew because he refused to participate. The remaining 105 patients
participated in this study.
Thirty-five (33.3%) of the 105 patients developed a pressure ulcer. Of those, 20 were
Stage I and 18 were Stage II. Most of the pressure ulcers were located at the sacrum
(73.7%) and heel (13.2%). Only 3 patients had more than one pressure ulcer (Table 1).
In table 2, there was no statistically significant difference based on age and length of
stay. In this study, the most common disease diagnosed was stroke, followed in order by
head trauma, cardiac disorder, post operation and diabetes mellitus. Five sub-categories
from the Braden Scale showed a statistically significant difference in sensory
perception, moisture, mobility, nutrition, friction & shear between patients who did and
did not develop a pressure ulcer.
The following additional risk factors showed a statistically significant difference
between patients who did and did not have a pressure ulcer. These factors are interface
pressure, iliac measure, body temperature, skin moisture, fecal incontinence and
smoking.

Correlations between variables detailed in table 3 and 4 were analyzed. This analysis
showed that friction & shear had better correlation coefficients with sensory perception,
moisture and mobility (range 0.60 to 0.79), while interface pressure, iliac measure,
nutrition, body temperature, and fecal incontinence showed weak correlation
coefficients. While smoking and body temperature showed independent.
A stepwise discriminant analysis evaluated eight significant variables (friction & shear,
nutrition, mobility, interface pressure, iliac measure, body temperature, smoking and
fecal incontinence) to investigate which ones would contribute most to the
discrimination between groups. A single discriminant function was calculated. In table
5, the value of this function was significantly different for pressure ulcer positive and
pressure ulcer negative patients (canonical correlation r = .67 ; Chi-square = 60.158,
degree of freedom = 4, p value = .000, and Wilks Lamda = 0.551). The correlation
between predictor variables and the discriminant function suggested that risk factors for
friction & shear, interface pressure, skin moisture and smoking were the best predictors
of pressure ulcers. The classification results determine how well group membership
could be predicted. These results showed that discriminant analysis correctly predicted
overall group membership at 84%, with accurate predictions being made for 77.1% of
patients who did develop pressure ulcers and 87.1% of patients who did not develop
pressure ulcers (table 5). .

Discussion
The results provide some evidence for the utility of the prediction of risk factors for
pressure ulcer development in Indonesia. In particular, the findings support the
importance of friction & shear, interface pressure, skin moisture and smoking as risk
factors associated with pressure ulcer development. Only friction & shear as a sub risk

factor from the Braden Scale contributed to pressure ulcer development. Our study
identified two risk factors (interface pressure and skin moisture) which have not yet
been investigated in previous studies in an intensive care unit. Our study also showed
that smoking as predictive factor in pressure ulcer development.
Interface pressure
Our study found that interface pressure was positively correlated with the
discriminant function value. This means that patients with higher interface pressure
values are at risk of developing a pressure ulcer. This study confirmed previous
research, which used the same instrument (pressure scanning-aid) for elderly patients 11.
In the final analysis, sensory perception and decrease mobility from the Braden Scale
did not contribute to risk of pressure ulcer development. The interface pressure is
identified as an important factor in the development of pressure ulcers and could be
assessed by measuring instrument objectively such as pressure evaluator rather than
identifying sensory perception, activity and mobility subjectively. In our study, we
concluded that pressure ulcer development might be influenced by support surfaces and
also body shape. The risk of developing a pressure ulcer for patients who used standard
equipment is high.12
Skin moisture
In the final analysis, moisture from the Braden Scale was not included. The reason for
this is because skin moisture can be caused by faecal incontinence, leaking wounds and
sweating due fever and higher ambient body temperature 13. Our finding concluded that
high skin moisture level is closely related to pressure ulcer development, it was caused
by faecal incontinence and sweating due to fever or high body temperature which were
found a statistically significant finding (tables 2). We did not find a correlation between

room humidity/temperature and pressure ulcer risk. This might be due to air
conditioning, which maintained near-constant temperature and humidity in the room. A
study in a natural environment (without using air conditioners) would be something to
consider in the future.
Smoking
This study conflicts with previous research in an intensive care unit, which reported
that smoking had no correlation with pressure ulcer development 4,14. However, this
finding confirmed with other studies that smoking was a potential risk factor in tissue
breakdown or pressure ulcers15,16. Our study found that patients who smoked less then
ten cigarettes per day did not develop pressure ulcer. This finding indicated that ICU
patients who consumed heavy of nicotine and tar level of cigarettes which contributed
to the development of pressure ulcer. If we compare with previous research in ICU
setting, it maybe there is any difference between the amount of tar and nicotine on a
cigarette and filter design that are received by smoker. Nicotine inhibits the release of
prostacyclin and thus causes vasoconstriction17. This condition may lead to ischemia of
tissue and consequently tissue damage. Further evaluation concerning the effect of tar
and nicotine, length of smoking and its relation to pressure ulcer risk is necessary.
Friction and shear
Although friction and shear is an important factor for pressure ulcer development, it
is difficult to measure friction & shear stress quantitative in a clinical setting. On the
final analysis showed that friction & shear was positively correlated with the
discriminant function value. Increasing the amount of friction & shear and interface
pressure cause microcirculatory occlusion resulting in ischemia, which leads to tissue
anoxia and it leads to cell death, necrosis, and ulceration. In this study, friction & shear

10

contributed to the development of pressure ulcer, it may be due to body weight, high
interface pressure, sweating and patients position on the bed with 10 to 30-degree of
head was raised, and bad mattresses design which the patients are more likely to slide
down easily. Next future study that identifies skin moisture level, interface pressure and
positioning related to friction & shear is needed.

This study was limited to the patients who were admitted in the intensive care unit in
one public hospital in Indonesia. The researcher did not identify any underlying
diseases, conditions, medications or other treatments that the patients may have been
receiving up until the time they were admitted to the intensive care unit. So, the effect of
any underlying diseases, etc. upon the development of pressure ulcers is unknown. In
addition, potential limitation of the study is related to the others sample or ICU unit. It
means that need to generalize to patients with other intensive care unit in ASEAN
people, and or other in developing country.

Implication for the clinical setting

The interface pressure and skin moisture factors have the additional advantage that
they are quantitative and objective. Therefore, patients who are admitted to the intensive
care unit would benefit by being identified early using a pressure scanning-aid and
moisture checker to evaluate skin moisture level everyday. In future research, the
development of a new scale using scanning-aid pressure, moisture checker, friction and
shear and smoking will be attempted in a clinical setting to predict pressure ulcer
development more accurately.

Conclusion
In this study, we confirmed that interface pressure, skin moisture, smoking and

11

friction & shear are risk factor of major importance for pressure ulcer development in
the ICU setting in Indonesia. Furthermore, we have shown that some of risk factors can
be measured objectively using a pressure-scanning aid and moisture checker non
invasive measurement technique at a skin site common for the development of pressure
ulcers.

Acknowledgment.
One institution provided the primary research support and technical assistance for this
study: St. Antonius Public Hopsital, Sei Jawi Pontianak, Indonesia. I am grateful to the
Director of St. Antonius who provided permission and moral support for this study.

References

12

1. Sugama J, Sanada H, Kanagawa K, Inagaki M, Nishimura M, Hiramatsu T, Yoshio

K, Kofuji Ml. Study on the risk factors of pressure sore development in the
intensive
care
unit
with
pressurerelieving
care.
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Al.Med.Prof.Kanazawa Univ 1992;16: 1-7.
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associated factors and assessing the utility of two pressure sore risk assessment
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pressure ulcers in a neuralgic intensive care unit. Critical Care Medicine 2001;
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pressure sore risk. Nursing Research 1987; 36(4): 205-210.
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M. Reliability and validity of a new multi-pad pressure evaluator for pressure
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13

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an acute medical unit. Journal of ET Nursing 1992; 19:160-165.
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Table 1. Characteristics of pressure ulcer development

Variable
n (%)
Incidence

14

Pressure ulcer positive

Pressure ulcer negative
Patients with more than one location of pressure ulcer
Stage
Stage I
Stage II
Stage III
Stage IV
Location of pressure ulcer
Sacrum
Heel
Trochanter
Elbow
Vertebrae
Scapula

35 (33.3)
70 (66.7)

3 ( 8.6)
20 (52.6)
18 (47.4)
0(0)
0(0)

28 (73.7)
5 (13.2)
1 ( 2.6 )
2 ( 5.3 )
1 ( 2.6 )
1 ( 2.6 )

15

Table 2. Demographic and other descriptive characteristics of pressure ulcer

positive (+) and pressure ulcer negative (-) subjects
Variables

PU+

PU-

Statistic

Age (years)

50.917.0 47.517.6

p-value

t = .83

.34

Gender (n)
Male
Female

24

48

11

= .000

<.05

22

Length of stay (days)

5.72.1

Diagnosis (n,%)

6.04.0

14(40%)
5(25%)
3(27%)
2(29%)
4(40%)
7(26%)

Stroke
Head trauma
Myocardial infarction
Post operation

t = -.48

.63

21(60%)
15(75%)
8(73%)
5(71%)
1(20%)
20(74%)

Diabetes mellitus
Others
Interface pressure(mmHg)
43.5 14.7 31.113.3
Iliac measure
42.7 7.1.
43.92.5
Skin moisture(%)
34.5 3.3
32.22.7
Diastolic blood pressure (mmHg)
73.319.9
77.812.9
Systolic blood pressure (mmHg)
126.213.0 128.918.8
Triceps
skinfold (mm)
Smoking
15.18.5
15.79.4
Albumin (g/)
3.71.1
3.891.0
10 or more
cigarette /day
16
Hemoglobin
(mg/)
12.22.8
12.62.9
Body
Fecaltemperature
incontinence()
36.81.0
36.30.7
Braden score (point)
10.52.9
13.32.5
Incontinence
34
Room
humidity (%)
56.67.9
57.56.8
Room temperature()
25.33.6
24.81.5
Smoking
Faecal incontinence
Non incontinence

t = 4.44
t =-2.47
t = 3.66
t =-1.22
t =-0.49
t =-0.32
t =-0.92
t = 0.66
t = 2.42
t =-5.38
t =-0.60
t = 1.70
= 14.37
= 3.81

.000*.
.015*
.000*
.227
.624
.747
.359
.509
.019*
.000*
.549
.092
.001*
.051*

Braden Scales
Sensory perception
Moisture
Mobility
Activity
Nutrition
Friction and shear

= 19.07
= 23.30
= 17.07
= 2.25
= 4.21
= 20.96

.001*
.001*
.001*
.325
.024*
.001*

Note. Values are mean standard deviation (SD), PU (pressure ulcer) * significant level, t- test pvalue < 0.01, Chi square p- value < 0.05
16

Table 3. Pearson correlation coefficient between items on the interface

pressure, skin moisture, iliac measure, and body temperature
Item

1.
2.
3.
4.

Interface pressure
Iliac measure
Skin moisture
Body temperature

1
-.20*
-.06
-.04

1
-.00
.04

1
.271**

*p < 0.05; ** p < 0.01 (two-tailed).

Table 4. Spearman correlation between items on the Braden Scale,

smoking and incontinence
Item

1
1. Sensory perception .57**
2. Moisture
.72**
3. Mobility
.20*
4. Nutrition
.67**
5. Friction & shear - .04
6. Smoking
.35**
7. Faeca incontinence

1
.56**
.19
.60**
- .06
.33**

1
- .02
.40**

1
.06

1
.14
.79**
- .00
.32**

1
.13
.18
.09

*p < 0.05; ** p < 0.01 (two-tailed).

17

Table 5. Standardized discriminant coefficient for stepwise procedure

Variable selected
Coefficients
1. Interface pressure
.597
2. Skin moisture
.590
3. Friction and shear
.568
4. Smoking
.527
Note: (canonical correlation r = .67, = 60.158, p value = .000, df = 4, Wilks Lamda = .551 )

Classification results of groups by predictor variables

Predicted group
Pressure ulcer (+) Pressure ulcer (-) Total
Pressure ulcer (+) 27 (77.1%)
8(22.9%)
35
Actual group
Pressure ulcer (-) 9 (12.9%)
61(87.1%)
70
Percent of "Grouped" cases correctly classified: 84 %.

18

Q
U
A
L
I
T
A
T
I
V
E

Independent variables

Sensory perception
Mobility
Activity
Friction & shear
Moisture
Nutrition
Faecal
incontinence

Independent variables

Pressure

Pressure ulcer
development
Dependent variables

Tissue
tolerance

Interface pressure

Skin moisture
Environmental moisture:
Room temperature
Room humidity
Nutritional condition;
Albumin,
Hemoglobin
Triceps skinfold
Iliac measure
Age
Diastolic pressure
Systolic pressure
Body temperature
Smoking

Q
U
A
N
T
I
T
A
T
I
V
E

Figure 1. A conceptual framework for this study of the etiology of pressure ulcer
based on Bradens Concepts, which have been modified

10. Suriadi, Kitagawa, Sanada, et al.: Study of reliability and validity of the Braden

Scale translated into Indonesian. 2nd world union wound healing society. July 8 th
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2. Langemo D K, Olson B, Hunter S, Hanson D, Burd C, Cathcart-Silberberg T.
Incidence and prediction of pressure ulcers in five patient care settings.
Decubitus 1991; 4(3): 25-32.

19

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5. Sugama J, Sanada H, Kanagawa K, Inagaki M, Nishimura M, Hiramatsu T, Yoshio
K, Kofuji Ml. Study on the risk factors of pressure sore development in the
intensive
care
unit
with
pressurerelieving
care.
MEMOIRS
AL.MED.PROF.KANAZAWA UNIV 1992;16: 1-7.
6. Brandeis GH, Ooi WL, Hossain M, Morris JN, Lipsitz LA. A longitudinal study of
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