CLINICAL RESEARCH

Risk factors in the

development of pressure
ulcers in an intensive care
unit in Pontianak, Indonesia
Suriadi, Hiromi Sanada, Junko Sugama, Atsuko Kitagawa, Brian Thigpen,
Sachiko Kinosita, Shizuko Murayama

Suriadi, Sanada H, Sugama J, Kitagawa A, Thigpen B, Kinosita S, Murayama S. Risk factors in the development of
pressure ulcers in an intensive care unit in Pontianak, Indonesia. Int Wound J 2007;4:208–215.

ABSTRACT
The purpose of this study was to identify risk factors associated with the presence of pressure ulcer development
in adult patients at an intensive care unit hospital in Indonesia. The prospective cohort design was conducted in
this study. A total of 105 patients participated and a pressure ulcer developed in 35 patients. The initial analysis
identified several variables as significant risk factors for pressure ulcer development (interface pressure, fecal
incontinence, skin moisture, diastolic blood pressure, smoking and body temperature). However, when entered
into a final multivariate analysis, four factors, interface pressure [odds ratio (OR) 17
6, 95% confidence interval
(CI) 4
1, 74
3], skin moisture (OR 8
2, 95% CI 2
2, 30
9), smoking (12
7, 95% CI 2
8, 56
7) and body
temperature (OR 102
0, 95% CI 7
7, 98
8) were found to be significant. The results suggest that interface
pressure measured using a multipad pressure evaluator, skin moisture measured by a moisture checker,
thermometer for body temperature and smoking status are adequate instruments for the prediction of pressure
ulcer development.
Key words: Intensive care unit • Pressure ulcers • Prospective cohort • Risk factor

Key Points
• the high incidence of pressure
ulcers in Indonesia may be that
there is no evidence-based risk
assessment scale used for pre-
diction of pressure ulcers, and
risk factors for pressure ulcer
development have not yet been
identified
• the identification of specific risk
factors for pressure ulcer devel-
opment in the ICU setting is
important so that nurses can
assess risk factor and reduce
the incidence of pressure ulcers
Authors: Suriadi, MSN, RN, Department of Clinical Nursing,
Graduate School of Medical Science, Kanazawa University, 5-
11-80 Kodatsuno, Kanazawa 920-0942 Japan; H Sanada, PhD,
RN, 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; J Sugama, PhD, RN, Department of Clinical Nursing,
Graduate School of Medical Science, Kanazawa University, 5-
11-80 Kodatsuno, Kanazawa 920-0942 Japan; A Kitagawa,
PhD, RN, 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; B Thigpen, MEd, Consultant Education, Faculty of
Education, University Tanjungpura Pontianak, Indonesia;
S Kinosita, MSN, RN, The Center of Nutritional Support &
Infection Control (CNI), Division of Nursing, Gifu University
Hospital, 1-1, Yanagido, Gifu city, 501-1194 Japan;
S Murayama, MSN, RN, Department of Clinical Nursing,
Graduate School of Medical Science, Kanazawa University,
5-11-80 Kodatsuno, Kanazawa 920-0942 Japan
Address for correspondence: Suriadi, Public Hospital
Soedarso in Pontianak, West Kalimantan, Pontianak 78124,
Indonesia
E-mail: suriadif@yahoo.com.au
INTRODUCTION
In Indonesia, the data collected from a 15-bed
intensive care unit (ICU) at a Pontianak Public
Hospital (Pontianak City, West Kalimantan,
formerly known as Borneo Island) from
January to June 1999 showed a pressure ulcer
incident rate of 29%. This is still exceptionally
high considering the incident rates in Asian
countries which range from 2
1% to 31
3% in
the ICU setting (1–3). 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 rely on their clinical judgement
to identify risk of pressure ulcer development
and planning nursing interventions. Therefore,
the identification of specific risk factors for

208 ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • Vol 4 No 3
 Risk factors in the development of pressure ulcers

pressure ulcer development in the ICU setting
is important so that nurses can assess risk factor
and reduce the incidence of pressure ulcers.
Some international studies were conducted
to identify risk factors for pressure ulcer
development in ICUs. These studies found
that factors associated with pressure ulcer
development were moisture and sensory per-
ception from Braden scale, circulation, fecal
incontinence, anaemia, length of stay, norepi-
nephrine, coma/unresponsivness/paralysed and
sedated, cardiovascular instability, infection,
age, patient status, skin condition and total
Braden score (4–8). 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 risk factors
such as interface pressure, and skin moisture that
have not yet been proven in previous studies in
an 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 ulcer devel-
opment in an ICU in Indonesia, from February
to July 2003.
Setting
The study was conducted in a 15-bed ICU with
a capacity of 300 beds at St Antonius, a public
hospital in Pontianak which is an urban area in
Indonesia.
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,
admitted to the ICU at least 24 hours before
at any time without giving a reason, or if
a patient developed a pressure ulcer, or died
Key Points
during the study, they were withdrawn. • the aim of this study was to
identify risk factors that are
The conceptual framework associated with the develop-
The study was conceptualised model of ment of pressure ulcers in the
schema which consists of two kinds of ICU setting in Indonesia
• moreover, the researcher at-
variables: dependent (pressure ulcer develop-
tempted to scientifically prove
ment) and independent variables (risk factors).
some of the risk factors such as
Tissue ischaemia and tissue tolerance are the interface pressure, and skin
core concepts of the schema, representing the moisture that have not yet
major factors affecting pressure ulcer develop- been proven in previous studies
in an ICU
ment. Tissue ischaemia is a result of blood flow
• for this purpose, the following
reduction in tissue causing a deficiency of
research question is formu-
oxygen and other nutrients essential for lated; which risk factors are
metabolic demands of the tissue. Continuous associated with the presence of
occlusion of blood will create a deprivation of pressure ulcers in the ICU
setting in Indonesia
oxygen, nutrients and waste removal of the
tissue. With the accumulation of toxic meta-
bolic byproducts produced by the cells, the
tissue begins to deteriorate and eventually dies
(9). Secondary factor contributing to tissue
ischaemia is interface pressure. Tissue toler-
ance was defined as ‘the ability of both the skin
and its supporting structures to endure the
effects of pressure without adverse sequelae’
(10). Secondary factors influencing tissue tol-
erance are fecal incontinence, skin moisture,
environmental moisture (room temperature,
room humidity), albumin, haemoglobin, triceps
skinfold, diastolic pressure, systolic pressure,
body temperature and smoking (Figure 1).
Outcome measures
Pressure ulcers were identified and classified
using the National Pressure Ulcer Advisory
Panel (NPUAP) (11). The skin condition of
each patient was assessed daily by the 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
Interface pressure Tissue
Ischemic

enrolment in the study, expected length of stay

Pressure ulcer
Fecal incontinence
at least 3 days (72 hours) after initial data Skin moisture development
collection, and gave informed consent. Exclu- Environmental moisture:
Room temperature
sion criteria: any patient who was physically Room humidity Tissue
Albumin, Tolerance
incapable of participating (difficult to identify Hemoglobin
Triceps skinfold
the skin condition everyday because patient Diastolic blood pressure
could not be manipulated), or any patient who Systolic blood pressure
Body temperature
did not wish to participate in this study was Smoking

excluded. Withdrawal criteria: Any patient who Figure 1. A conceptual framework for this study of the
wished to withdraw from the study could do so etiology of pressure ulcers.

ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc 209

Key Points
• several variables were identi-
fied as risk factors for pressure
ulcer development: interface
pressure, skin and environmen-
tal moisture, nutritional condi-
tion, body temperature and
blood pressure, smoking, and
finally fecal incontinence
210
Risk factors in the development of pressure ulcers
white when it is pressed with a finger. If the
pressure ulcer appeared to be stage I, it was
examined and repeated 4–6 and 24 hours later
to distinguish it from transient reactive hyper-
emia. Skin assessment included documenta-
tion of the anatomic location and stage.
Independent variables measurement
Interface pressure
Interface pressure was recorded using a multi-
pad pressure evaluator (Cello
, Cape Co. Ltd,
Tokyo, 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. A multipad pressure evaluator is used to
measure interface pressure. The intrarater reli-
ability of the multipad pressure evaluator
coefficient of variation was 6
4  12% in a group
of nurses inexperienced at measuring pressures.
The interrater reliability of interface pressure
measurement was 11
4  11
9%. Then a validity
test found that cutoff scores for discriminating
between patients with and without pressure
damage were in the region of 40 mmHg or
more for elderly hospital patients (12).
Skin and environmental moisture
Skin moisture was measured by using a mois-
ture checker. An accuracy of the instrument
was reported that the interrater reliability for
this instrument is 0
2% (MY707s, Scalar
America, Scalar Kabushiki Company, Tokyo,
Japan). Room humidity and temperature were
measured using a humidity- and temperature-
monitoring device, the accuracy of these
instruments are 0
1C and 5% at 23C,
respectively (Hygrometer
, Sato Keiryoki Mfg.
Co. Ltd, Tokyo, Japan).
Nutritional condition
To evaluate nutritional condition, the albumin
and haemoglobin count in the blood were
measured using a blood-monitoring device
(Photo Meter 4020
, Boehringer Mannheim Co.,
Mannheim, Germany). The skinfold thickness
at the triceps was measured by simple skinfold
callipers (Dainato Co. Ltd, Tokyo, Japan).
Body temperature and blood pressure
Body temperature was measured using an
electronic thermometer. The accuracy of this
instrument is 0
1C (C863
, Terumo Medical
Products Co. Ltd, Tokyo, Japan). Blood pres-
sure was measured using a blood pressure-
monitoring device [MDE Escort Prism
,
ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Advance Medical System (M) Sdn. Bhd. Co.,
Kuala Lumpur, Malaysia].
Smoking
To collect data for smoking status, we recorded
the number of cigarettes/day. We classified the
patients into two categories: smoke more than
10 cigarettes/day, smoke less than 10 cigar-
ettes/day and/or not currently smoking.
Fecal incontinence
Previous study found that fecal incontinence was
significant in pressure ulcer development (6).
However, fecal incontinence has not been iden-
tified adequately in an ICU. Fecal incontinence
was assessed by using categorical yes and no.
Procedures
Before starting the study, three nurse’s practi-
tioners at the same level were oriented and
trained in the purposes and procedures of the
study. The researcher selected the patients for
this study within 24 hours after being admitted
to the ICU. The study was explained to all
eligible participants. In this case, the patients
were sedated, unconscious or incompetent.
Informed consent was obtained from their
family. Patients’ families received verbal and
written explanations of the study and proced-
ures. All patients/family who wished to par-
ticipate in the study signed a consent form.
Demographic data were collected at the
beginning of the study. Interface pressure
measurement was taken at the patient’s
sacrum after the 24-hour monitoring period
had expired for a newly admitted patient to
the ICU. The skin moisture procedure was
conducted in the same manner as the interface
pressure. Room humidity and temperature
measurement were measured three times daily.
The triceps skinfold measurement was taken
by placing the instrument callipers over the
midpoint of the skinfold on the right side of
the body for each patient. This procedure was
assessed twice a week and repeated three
times during each assessment, and the mean
score was used. Body temperature and blood
pressure were conducted three times daily.
Smoking data were obtained from the patient’s
medical records and/or family. We also daily
assessed the fecal incontinence status of all
patients and reconfirmed by medical records.
If a pressure ulcer was identified, the research-
ers stopped their assessment and the patient
was withdrawn from the study. In instances of

skin breakdown, interventions are implemented
to treat and/or prevent deterioration by staff
nurses.
Data analysis
Descriptive analysis was used to identify some
of demographic data, characteristic of pressure
ulcers development and characteristic of risk
factors. To evaluate the relationship between
the risk factor variables and pressure ulcer
development, the relation of various potential
risk factors with the pressure ulcer develop-
ment (outcome) was statistically evaluated
using univariate analysis. Variables showing
statistically significant association with pres-
sure ulcer development at P , 0
20 were
considered as potential risk factors for inclu-
sion in binary multivariate logistic regression
analysis. The odds ratio (OR) and 95% confi-
dence interval were calculated for each of
the statistically significant risk factors. In
this study, a P value ,0
05 was considered as
statistically significant.
Previous study was used which the continu-
ous variables (interface pressure, skin mois-
ture, body temperature, room humidity and
room temperature) were dichotomised using
cut points confirmed by receiver operating
curve analyses (13). For patients who devel-
oped a pressure ulcer, risk factors obtained in
the last assessment before pressure ulcer
development were used and for patients who
did not develop a pressure ulcer, their mean
score was obtained. All analyses were per-
formed using SPSS statistical software (version
11; SPSS, Chicago, IL).
RESULTS
Total subjects admitted to the ICU were 297
patients of which, 191 patients were excluded
from this study for various reasons; they had
pressure ulcers when admitted, were 1-day care,
able to ambulate, were 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 de-
veloped 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 three patients
had more than one pressure ulcer (Table 1).
There was no significant difference based on
age and length of stay. The most common
ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Risk factors in the development of pressure ulcers
disease diagnosed was stroke, followed in
order by head trauma, myocardial infarction,
Key Points
postoperation and diabetes mellitus. • 105 patients participated in
The results of univariate analyses are this study
described in Table 2. Six variables which were • 35 of the 105 developed a
pressure ulcer
independently associated with risk of pressure
• there was no significant differ-
ulcer development, interface pressure (OR 7
2, ence in age and length of stay
P ¼ 0
000), fecal incontinence (OR 0
2, P ¼ • the findings support the impor-
0
051), skin moisture (OR 5
5, P ¼ 0
000), tance of interface pressure, skin
diastolic blood pressure (OR 0
2, P ¼ 0
19), moisture, smoking and body
temperature as significant risk
smoking (OR 5
1, P ¼ 0
001) and body
factors for pressure ulcer devel-
temperature (OR 20
4, P ¼ 0
001). While the opment
variables were simultaneously considered in
a multivariate logistic regression analysis, we
found that interface pressure, skin moisture,
smoking and body temperature are remaining
significant risk factors for pressure ulcer
development (Table 3).
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 interface pressure, skin moisture, body
temperature and smoking as risk factors asso-
ciated with pressure ulcer development.
Interface pressure
Our study found that interface pressure was
significant risk factor for pressure ulcer develop-
ment. 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
(multipad pressure evaluator) for elderly pa-
tients (12). Most patients in the ICU are immobile
as a result of ventilation, unconsciousness and/
or sedation. Thus, we postulated that interface
pressure is identified as an important factor in the
development of pressure ulcers and could be
assessed by a measuring instrument which can
objectively complement sensory perception,
activity and mobility. In our study, we con-
cluded that pressure ulcer development might
be influenced by support surfaces which use
standard mattresses and also body shape. The
risk of developing a pressure ulcer for patients
who use standard mattresses is high (14).
Skin moisture
In the final analysis, skin moisture was
associated with pressure ulcer. The reason for
this is because skin moisture can be caused
211
 Risk factors in the development of pressure ulcers

Table 1 Demographic and characteristics of pressure ulcer development

Variables Pressure ulcer positive Pressure ulcer negative Statistic P value

Age (years) 50
9  17
0 47
5  17
6 t ¼ 0
83 0
34

Gender (n)
Male 24 48 x2 ¼ 0
000 ,0
05
Female 11 22
Length of stay (days) 5
7  2
1 6
0  4
0 t ¼ 0
48 0
63
Diagnosis, n (%)
Head trauma 14 (40) 21 (60)
Stroke 5 (25) 15 (75)
Myocardial infarction 3 (27) 8 (73)
Postoperation 2 (29) 5 (71)
Diabetes mellitus 4 (40) 1 (20)
Others 7 (26) 20 (74)
Incidence, n (%)
Pressure ulcer positive 35 (33
3)
Pressure ulcer negative 70 (66
7)
Patients with 3 (8
6)
more than one pressure ulcer
Stage
I 20 (52
6)
II 18 (47
4)
III 0 (0)
IV 0 (0)
Location of pressure ulcer
Sacrum 28 (73
7)
Heel 5 (13
2)
Trochanter 1 (2
6)
Elbow 2 (5
3)
Vertebrae 1 (2
6)
Scapula 1 (2
6)

by fecal incontinence, leaking wounds and
sweating because of fever and a higher ambi-
ent body temperature (15). Our finding con-
cluded that if high skin moisture level is
closely related to pressure ulcer development,
it was caused by fecal incontinence and
sweating because of fever or high body
temperatures, which were found to be a signifi-
cant finding. We did not find a correlation
between room humidity/temperature and
pressure ulcer risk. This might be because of
air conditioning, which maintained near-con-
stant temperature and humidity in the room.
Smoking
This study conflicts with previous research in
an ICU, which reported that smoking had no
correlation with pressure ulcer development
(4,16). However, this finding confirmed other
studies stating that smoking was a potential
risk factor in tissue breakdown or pressure
ulcers (17,18). Our study found that patients
who smoked less then 10 cigarettes/day and/
or no current smoking did not develop
pressure ulcers. This finding indicated that
consuming heavy amounts of nicotine and tar
from cigarettes contributed to the development
of pressure ulcers in ICU patients. If we
compare with previous research in ICU set-
tings, it may be that there are differences in the
amount of tar and nicotine in a cigarette and
filter design that are used by smokers. Nicotine
inhibits the release of prostacyclin and thus
causes vasoconstriction (19). This condition
may lead to ischaemia of tissue and conse-
quently tissue damage. Further evaluation
concerning the effect of tar and nicotine, length
of smoking and its relation to pressure ulcer
risk is necessary.
Body temperature
Our finding showed that body temperature
has been associated with pressure ulcer devel-
opment in the ICU patients. This study

212 ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc
 Risk factors in the development of pressure ulcers

Table 2 Univariate analysis of risk factors for pressure ulcer development (n ¼ 105)

Risk factors Pressure ulcer positive) Pressure ulcer negative Odds ratio Confidence interval P

Interface pressure (mmHg)

.35 25 18 7
2 (2
9, 17
9) 0
000
,35 52 10
Fecal incontinence
Yes 34 59 0
2 (0
0, 1
2) 0
051
No 1 11
Skin moisture (%)
.34 21 15 5
5 (2
3, 13
3) 0
000
,34 14 55
Room temperature (C)
.24 26 45 1
6 (3
7, 3
9) 0
417
,24 9 25
Room humidity (%)
.59 28 58 0
8 (0
3, 2
3) 0
929
,59 7 12
Haemoglobin (mg/dl)
.12 20 44 0
8 (0
3, 1
8) 0
724
,12 15 26
Triceps skinfold (mm)
.12 18 34 1
1 (0
5, 2
5) 0
945
,12 17 36
Systolic blood
pressure (mmHg)
.90 32 69 0
2 (0
0, 1
5) 0
207
,90 3 1
Diastolic blood
pressure (mmHg)
.60 27 66 0
2 (0
1, 0
7) 0
019
,60 8 4
Smoking
.10 cigarettes/day 16 10 5
1 (2
0, 13
0) 0
001
,10 cigarettes/day 19 60
and/or not current smoking
Body temperature (C)
.37
4 8 1 20
4 (2
4, 171
3) 0
001
,37
4 27 69
Albumin (g/dl)
.12 20 41 0
9 (0
4, 2
1) 0
889
,12 15 19

confirmed with other studies that there was

Table 3 Multivariate analysis of risk factor for pressure ulcer relationship between pressure ulcer develop-
development ment and body temperature (20,21).
95% In rat or man, increased temperature causes
Odds confidence an exponential increase in perfusion. Increased
Risk factors ratio interval P perfusion in humans has been associated with
an increase in core body temperature as well as
Interface pressure 17
6 (4
1, 74
3) 0
000
in local skin temperature (20). Increase in body
Skin moisture 8
2 (2
2, 30
9) 0
002
temperature alone may not cause any signifi-
Smoking 12
7 (2
8, 56
7) 0
001
cant damage. However, increase in body
Body temperature 102
0 (7
7, 98
8) 0
001
temperature and adding long periods of

ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc 213

Key Points
• in future research, the devel-
opment of a new scale using
a multipad pressure evaluator
aid, moisture checker, body
temperature and smoking will
be attempted in a clinical set-
ting to predict pressure ulcer
development more accurately
in Indonesia
• in this study, we confirmed that
interface pressure, skin mois-
ture, smoking and body tem-
perature are risk factors of
major importance for pressure
ulcer development in the ICU
setting in Indonesia
• we have shown that some
of the risk factors can be
measured objectively using a
multipad pressure evaluator,
thermometer and a moisture
checker with a non invasive
measurement technique at
common bony prominences for
the development of pressure
ulcers
214
Risk factors in the development of pressure ulcers
exposure to interface pressure could cause skin
tissue to increase perfusion and stiffer (9,21).
This condition may result in continuous
occlusion of blood flow, restriction of lymph-
atic circulation, and resulting in ischaemia,
then leads to ulceration.
This study was limited to the patients who
were admitted in the ICU 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 ICU. So, the
effect of any underlying diseases, upon the
development of pressure ulcers is unknown.
Implication for the clinical setting
The interface pressure, body temperature,
smoking and skin moisture factors have the
additional advantage that they are quantitative
and/or objective. Therefore, patients who are
admitted to the ICU would benefit by being
identified early using a multipad pressure
evaluator, thermometer for body temperature,
smoking status and moisture checker to
evaluate skin moisture level everyday. In
future research, the development of a new
scale using a multipad pressure evaluator aid,
moisture checker, body temperature and smok-
ing will be attempted in a clinical setting to
predict pressure ulcer development more
accurately in Indonesia.
CONCLUSION
In this study, we confirmed that interface
pressure, skin moisture, smoking and body
temperature are risk factors of major import-
ance for pressure ulcer development in the ICU
setting in Indonesia. Furthermore, we have
shown that some of the risk factors can be
measured objectively using a multipad pres-
sure evaluator, thermometer and a moisture
checker with a non invasive measurement
technique at common bony prominences for
the development of pressure ulcers.
ACKNOWLEDGEMENTS
One institution provided the primary research
support and technical assistance for this study:
St Antonius Public Hopsital, Sei Jawi Pontia-
nak, Indonesia. I am grateful to the Director of
St Antonius who provided support for this
study.
ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc
REFERENCES
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
pressure–relieving care. Memoirs Al Med Prof
Kanazawa Univ 1992;16:1–7.
2 Seongsook J, Ihnsook J, Younghee L. Validity of
pressure ulcer risk assessment scales; Cubbin and
Jackson, Braden scale and Douglas scale. Int J
Nurs Stud 2004;41:199–204.
3 Kwong E, Pang S, Wong T, Ho J, Shao-ling X, Li-jun
T. Predicting pressure ulcer risk with the modified
Braden, Braden and Norton scales in acute care
hospital in Mainland China. Appl Nurs Res
2005;18:122–8.
4 Jiricka MK, Ryan P, Carvalho MA, Bukvich J.
Pressure ulcer risk factors in ICU population.
Am J Crit Care 1994;4:361–7.
5 Carlson EV, Kem MG, Shott S. Predicting the risk of
pressure ulcers in critically ill patients. Am J Crit
Care 1999;8:262–9.
6 Bours GJJW, De Laat E, Halfens RJG, Lubbers M.
Prevalence, risk factors and prevention of pressure
ulcers in Dutch intensive care units. Intensive Care
Med 2001;27:1599–1605.
7 Boyle M, Green M. Pressure sores in intensive
care: defining their incidence and associated
factors and assessing the utility of two pressure
sore risk assessment tools. Aust Crit Care 2001;14:
24–30.
8 Fife C, Otto G, Capsuto EG, Brandt K, Lyssy K,
Murphy K, Short C. Incidence of pressure ulcers in
a neuralgic intensive care unit. Crit Care Med
2001;29:283–90.
9 Chang WL, Seireg AA. Prediction of pressure ulcer
formation on the skin. Med Hypothesis 1999;2:
141–4.
10 Bergstrom N, Braden B, Laguzza A, Holman V. The
Braden scale for predicting pressure sore risk.
Nurs Res 1987;36:205–10.
11 Fisher AR, Wells G, Harrison MB. Factors asso-
ciated with pressure ulcers in adults in acute
care hospitals. Adv Skin Wound Care 2004;17:
80–90.
12 Sugama J, Sanada H, Nakano N, Masuya N, Tabata
K, Kumakawa Y, Takahashi M. Reliability and
validity of a new multi-pad pressure evaluator for
pressure ulcer management. J Tissue Viability
2002;12:148–53.
13 Suriadi, Sanada H, Kitagawa A, Kinosita S,
Murayama S. Factors associated with pressure
ulcer in the ICU [in Japanese]. Jpn J Press Ulcers
2004;6:3.
14 Russell LJ, Reynolds TM, Park C, Rithalia S,
Gonsalkorale M, Birch J, Torgerson D, Iglesias C.
Randomized clinical trial comparing 2 support
surfaces: results of the prevention of pressure ulcers
study. Adv Skin Wound Care 2003;16:317–27.
15 Keller BPJA, Wille J, Ramshorst Bv, Werken Cvd.
Pressure ulcers in intensive care patients: a review
of risk and prevention. Intensive Care Med
2002;28:1379–88.

16 Salvadalena GD, Snyder ML, Brogdon KE. Clinical
trial of the Braden scale on an acute medical unit.
J ET Nurs 1992;19:160–5.
17 Noble M, Voegeli D, Clough GF. A comparison of
cutaneous vascular responses to transient pressure
loading in smokers and nonsmokers. J Rehabil Res
Dev 2003;40:283–8.
18 Hashimoto H. Impaired microvascular vasodilator
reserve in chronic cigarette smokers-a study of
post-occlusive reactive hyperemia in the human
finger. Jpn Circ J 1994;58:29–33.
ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Risk factors in the development of pressure ulcers
19 Tur E, Yosipvitch G, Oren-Vulfs S. Chronic and acute
effects of cigarette smoking on skin blood flow.
Angiology 1992;43:328–35.
20 Patel S, Knapp CF, Donofrio JC, Salcido R. Tem-
perature effects on surface pressure-induced
changes in rat skin perfusion: implications in
pressure ulcer development. J Rehabil Res Devel
1999;36:189–201.
21 Fisher AR, Andrea R. Factors associated with pres-
sure ulcers in adults in acute care hospitals. Adv
Skin Wound Care. 2004;17:80–90.
215