History Of Pressure Ulcers Research Articles

Hospital-acquired Pressure Ulcers in Trauma Patients: A Retrospective Study of 410 Patients at a Referral Trauma Center in the North of Iran

Background: Pressure ulcers (PUs) are among the most common chronic ulcers and complications of hospitalization. Objective: The present study aims to evaluate the prevalence of hospital-acquired PUs and their grades in trauma patients, comparing demographic characteristics, clinical features, and outcomes among patients without and with PUs referred to a trauma center in the North of Iran. Methods: In a retrospective study, 410 patients with trauma referred to a trauma center in the North of Iran were enrolled. Data were collected using a simple random sampling from March 2019 to September 2019. Results: The prevalence of PU in patients with trauma was 27.6%. Grade III (35.5%) and grade I (3.5%) wounds had the highest and lowest frequency of PU, respectively (P<0.001). The mean age of patients with PU was higher than patients without PU (61.73 vs. 47.71 years, P<0.001). The mean hemoglobin level of patients with PU was lower than patients without PU (9.93 vs. 12.25, P<0.001). PUs were more common in smokers compared to non-smokers (P<0.001), with a history of PU (P<0.001), a history of diabetes mellitus (P<0.001), and a history of hypertension (P<0.001). The mean length of stay in the hospital for patients with PU was higher than for patients without PU (13.02 vs. 5.54 days, P<0.001). 74.3% of people with PUs were completely immobile (P<0.001), and 60% of them had mild brain damage (GCS of 13 to 15). Also, the number of people with severe and moderate brain injury among PUs patients was 15% and 24.7%, respectively (P<0.001). Mobility, brain damage, Hemoglobin rate and smoking status were risk factors for pressure ulcers. Conclusion: Therefore, it is recommended that health managers and policymakers develop care and treatment plans by considering these risk factors.

Pressure ulcers in individuals with spinal cord injury: risk factors in neurological rehabilitation

Objective: to identify risk factors for the occurrence of pressure ulcers in adult individuals with spinal cord injuries in neurological rehabilitation. Methods: integrative review of studies published in the bases Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature and Latin American and Caribbean Literature in Health Sciences. Results: 308 studies were found, with six articles selected, based on pre-established inclusion criteria. The number of risk factors found was similar during and after neurological rehabilitation. Conclusion: the risk factors found for the occurrence of pressure ulcers during and after neurological rehabilitation, were related to sociodemographic conditions, the spinal cord injury itself, associated with clinical condition and behavior. With the exception of complete injury and a history of pressure ulcers, risk factors varied during and after rehabilitation stages.

Nomogram for pneumonia prediction among children and young people with cerebral palsy: A population-based cohort study.

BackgroundPneumonia is the leading cause of death among children and young people (CYP) with severe cerebral palsy (CP). Only a few studies used nomogram for assessing risk factors and the probability of pneumonia. Therefore, we aimed to identify risk factors and devise a nomogram for identifying the probability of severe pneumonia in CYP with severe CP.MethodsThis retrospective nationwide population-based cohort study examined CYP with newly diagnosed severe CP before 18 years old between January 1st, 1997 and December 31st, 2013 and followed them up through December 31st, 2013. The primary endpoint was defined as the occurrence of severe pneumonia with ≥ 5 days of hospitalization. Logistic regression analysis was used for determining demographic factors and comorbidities associated with severe pneumonia. These factors were assigned integer points to create a scoring system to identify children at high risk for severe pneumonia.ResultsAmong 6,356 CYP with newly diagnosed severe CP, 2,135 (33.59%) had severe pneumonia. Multivariable logistic regression analysis revealed that seven independent predictive factors, namely age <3 years, male sex, and comorbidities of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications. A nomogram was devised by employing these seven significant predictive factors. The prediction model presented favorable discrimination performance.ConclusionsThe nomogram revealed that age, male sex, history of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications were potential risk factors for severe pneumonia among CYP with severe CP.

Seated buttocks anatomy and its impact on biomechanical risk

AimThe objective of this study was to describe the amount, types, and shapes of tissue present in the buttocks during sitting (i.e., seated buttocks soft tissue anatomy), and the impact of seated buttocks soft tissue anatomy on biomechanical risk. Materials and methodsThe buttocks of 35 people, including 29 full-time wheelchair users with and without a history of pelvic pressure ulcers were scanned sitting upright on 3” of flat HR45 foam in a FONAR Upright MRI. Multi-planar scans were analyzed to calculate bulk tissue thickness, tissue composition, gluteus maximus coverage at the ischium, the contour of the skin, and pelvic tilt. ResultsBulk tissue thickness varied from 5.6 to 32.1 mm, was composed mostly of adipose tissue, and was greatest in the able-bodied cohort. Skin contours varied significantly across status group, with wheelchair users with a history of pressure ulcers having tissue with a peaked contour with a radius of curvature of 65.9 mm that wrapped more closely to the ischium (thickness at the apex = 8.2 mm) as compared to wheelchair users with no pressure ulcer history (radius of curvature = 91.5 mm and apex thickness = 14.5 mm). Finally, the majority of participants presented with little to no gluteus coverage over their ischial tuberosity, regardless of status group. ConclusionsThis study provides quantitative evidence that Biomechanical Risk, or the intrinsic characteristic of an individual's soft tissues to deform in response to extrinsic applied forces, is greater in individuals at greater risk for pressure ulcers.

Associations Between Insurance Provider and Assistive Technology Use for Computer and Electronic Devices 1 Year After Tetraplegia: Findings From the Spinal Cord Injury Model Systems National Database

ObjectiveTo investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. DesignMulticenter cross-sectional study. SettingParticipants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. InterventionsNot applicable. ParticipantsMen and women with tetraplegia (N=498) enrolled in the SCIMS National Database were included in the analysis. Main Outcome MeasuresThe primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject’s principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers’ compensation. ResultsOverall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers’ compensation were more likely to report AT use than individuals with either government or private insurance. ConclusionsDespite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers’ compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.

Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality.

Prospective cohort study. Identify the risk and protective factors of all-cause and cause-specific mortality among persons with traumatic spinal cord injury (SCI). Rehabilitation specialty hospital in the Southeastern United States. A prospective cohort study was conducted with 3070 adults with traumatic SCI who were a minimum of 1 year post-injury at assessment. Prospective data were collected in 1997-1998 and 2007-2010, with mortality determined as of 31 December, 2016. The deceased were classified into six categories based on underlying cause of death: septicemia, pneumonia and influenza, cancer, heart and blood vessel diseases, unintentional injuries, and all other causes. The competing risk analysis strategy applied to each of the specific causes. There were a total of 803 observed deaths among the 2979 final study sample. After controlling for demographic and injury characteristics, general health, pressure ulcer history, and symptoms of infections were significantly associated with all-cause mortality. Except for cancer, they were also related with at least one of the specific causes of death, whereas orthopedic complications and subsequent injuries were unrelated to any cause. Three health domains, global health, pressure ulcers, and symptoms of illness or infection, were significantly associated with mortality after SCI, and the patterns of association varied as a function of specific cause of death.

Developing risk-adjusted quality indicators for pressure ulcers in long-term care hospitals in the Republic of Korea.

Pressure ulcers result in financial losses, including the cost of unnecessary medical expenses because of extended hospital stays, treatment, and examination. This was a retrospective, observational, methodological study to develop quality indicators related to pressure ulcer development and validate risk adjustment factors for pressure ulcer development. We performed a literature review to develop risk adjustment factors, and an expert group performed a content validity test. To validate risk adjustment factors for pressure ulcer development using electronic medical records, 127 patients admitted to a long-term care hospital in South Korea from June to September 2015 were enrolled in the study. Pressure ulcer risk factors were peripheral vascular disease, end-stage disease, past pressure ulcer history, high risk group for pressure ulcer development, fever, haemoglobin, and albumin (all P < 0.05); only albumin (odds ratio: 0.210, P < 0.001) was significantly associated with pressure ulcer development as an independent risk factor. Further research with a large sample size is needed for the validation of risk adjustment factors. Risk-adjusted quality indicators for pressure ulcer development can be used to evaluate the quality of nursing care and compare outcomes after preventive pressure ulcer care activities or between long-term care hospitals.

Buttock tissue response to loading in men with spinal cord injury.

Objective/BackgroundDespite the fact that most people with a spinal cord injury who use a wheelchair for mobility are considered at-risk for pressure ulcer (PrU) development, there still exists a spectrum of risk amongst this group. Efforts to differentiate risk level would benefit from clinical tools that can measure or predict the buttocks response to loading. Therefore, the goal of this study was to identify how tissue compliance and blood flow were impacted by clinically-measurable risk factors in young men with SCI.MethodsBlood flow at the ischial tuberosity was measured using laser Doppler flowmetry while the seated buttock was unloaded, and loaded at lower (40–60 mmHg) and high (>200 mmHg) loads. Tissue compliance of the buttock was measured using the Myotonometer while subject were lifted in a Guldmann Net.ResultsAcross 28 participants, blood flow was significantly reduced at high loads, while no consistent, significant changes were found at lower loads. At 40–60 mmHg, blood flow decreased in participants with a pressure ulcer history and lower BMI, but stayed the same or increased in most other participants. The buttock displaced an average of 9.3 mm (2.7 mm) at 4.2 N, which represented 82% (7%) of maximum displacement. BMI was related to the amount of buttock tissue displacement while smoking status explained some of the variation in the percent of max displacement.ConclusionWide variability in tissue compliance and blood flow responses across a relatively homogeneous population indicate that differences in biomechanical risk may provide an explanation for the spectrum of PrU risk among persons with SCI.

Predictors of pressure ulcer risk in adult intensive care patients: A retrospective case-control study

ObjectivesTo evaluate the predictive power of risk factors for pressure ulcers in adult intensive care patients. MethodA retrospective case-control study was performed utilising a heterogeneous sample group allocated into a case group with pressure ulcers (n=90) and a control group without pressure ulcers (n=90). The analysis explored the predictive power of risk factors for pressure ulcers using a hierarchical logistic regression model. ResultsThe risk factors that predicted pressure ulcers were friction (OR=5.97), previous history of pressure ulcers (OR=5.43), prolonged intensive care unit stay (OR=3.92), dehydration (OR=3.18), elevated skin temperature by 1–2°C (OR=3.12) and treatment of other comorbidities (OR=2.79). ConclusionAdult intensive care patients have an increased risk of developing a pressure ulcer. These risk factors are regarded as strong predictors for pressure ulceration. This study advances nursing knowledge in that it investigates additional risk factors for the development of pressure ulcers and it identifies a set of factors that best predict their occurrence, which may contribute to the nurses' diagnostic reasoning in the intensive care unit.

Experience of Sleep in Individuals with Spinal Cord Injury and a History of Pressure Ulcers

To examine the subjective experience of sleep among individuals with SCI and a history of pressure ulcers.

Outcomes after Stroke in Patients with Previous Pressure Ulcer: A Nationwide Matched Retrospective Cohort Study

Factors associated with poststroke adverse events were not completely understood. The purpose of this study was to investigate whether stroke patients with previous pressure ulcers had more adverse events after stroke. Using the claims data from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study matched by propensity score. Three thousand two first-ever stroke patients with previous pressure ulcer and 3002 first-ever stroke patients without pressure ulcer were investigated between 2002 and 2009. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of complications and 30-day mortality after stroke associated with previous pressure ulcer were calculated in the multivariate logistic regressions. Patients with pressure ulcer had significantly higher risk than control for poststroke urinary tract infection (OR: 1.56, 95% CI: 1.38-1.78), pneumonia (OR: 1.35, 95% CI: 1.16-1.58), gastrointestinal bleeding (OR: 1.31, 95% CI: 1.04-1.66), and epilepsy (OR: 1.84, 95% CI: 1.83-1.85). Stroke patients with pressure ulcer had increased 30-day poststroke mortality (OR: 2.01, 95% CI: 1.55-2.61), particularly in those treated with debridement (OR: 2.87, 95% CI: 1.85-4.44) or high quantity of antibiotics (OR: 4.01, 95% CI: 2.10-7.66). Pressure ulcer was associated with poststroke mortality in both genders and patients aged 60 years or older. This study showed increased poststroke complications and mortality in patients with previous pressure ulcer, which suggests the urgent need for monitoring stroke patients for pressure ulcer history.

Factors influencing optimal seating pressure after spinal cord injury

Retrospective, cross-sectional design. To identify factors that predict unsatisfactory seating pressure in spinal cord-injured (SCI) individuals. Seating Clinic at the University Hospital, Norway. All wheelchair users with traumatic SCI hospitalized between 1 January 2007 and 31 December 2010 were included. Individual assessment by a team was performed. To measure seating pressure, a computerized seating pad with sensing points 40 × 40 cm was used. Primary end points were defined as satisfactory or unsatisfactory seating position based on measured pressure (more or less 100 mm Hg), clinical findings and physical activity level. To explore possible risk factors for high seating pressure, both univariate and multivariate regression analysis were performed. A total of 75 persons with SCI were assessed, 39 (52%) with unsatisfactory result. Statistical analysis revealed that use of manual wheelchair (odds ratio (OR)=6.86, confidence interval (CI) 1.77-26.63) and history of pressure ulcer (OR=8.47, CI 2.46-29.13) significantly increase the risk of unsatisfactory seating pressure. Paraplegia caused significantly higher risk (OR=2.5, CI 0.99-6.34) in the univariate model, probably because the SCI with tetraplegia do prefer electrically powered wheelchairs. Use of manually driven wheelchairs and persons with previous pressure ulcer are at significant risk of high seating pressure and consequently developing new pressure ulcers. The patients from these subcategories need close follow-up regarding seating position and prevention of pressure ulcers.

Evaluation of Risk for Pressure Ulcers Using the Braden Scale in Elderly Patients Receiving Long-Term Care

Background: Elderly patients receiving long-term care are at high risk for pressure ulcers. This study was done to identify histories of pressure ulcers and to evaluate the risk of pressure ulcers using the Braden scale. Methods: We enrolled 103 subjects receiving nursing homecare from a university hospital in Gyeongju or admitted to nursing homes in Pohang between April 1, 2010 and June 30, 2010. Assessment tools included demographic information, level of care, activities of daily living (ADL), presence of pressure ulcer, history of pressure ulcers and the Braden scale scores. Results: Twenty-six subjects (25.2%) had previous pressure ulcers. The mean Braden scale score was 15.02±4.23 (range, 6 to 23). And categorized into two groups based on previous pressure ulcers, the mean score was 11.92±3.59 for the group with previous pressure ulcers and 16.06±3.93 for the group without previous (p<0.001). The number of subjects with a risk for pressure ulcers according to the Braden scale was 71 (69.9%). The Braden scale had a positive correlation with level of care (p<0.001) and a negative correlation with ADL (p<0.001). Factors related to the history of pressure ulcers were homecare services (p=0.010), concurrent diabetes (p=0.023) and a low Braden scale score (p=0.028). Conclusion: We recommend that a pressure ulcer risk assessment be done routinely in elderly patients receiving longterm care services to minimize their occurrence.

Distinct tilting behaviours with power tilt-in-space systems

Purpose. To characterise the use of tilt-in-space systems and to form recommendations for tilt prescription and training based upon its use.Method. Wheelchair occupancy and seat position of 45 full-time power wheelchair users were monitored for 1–2 weeks using an accelerometer, occupancy switch and data logger. Demographics, pressure ulcer history, functional and physical presentations of their disability, and sensation were also documented.Results. Participants spent 12.1 h in their wheelchairs daily, with a median typical position of 8° (0°–47°). The median participant tilted every 27 min (0.1–16.6 tilts per occupancy hour). Pressure-relieving tilts (i.e. a tilt ≥30° for ≥1 min) were performed, on average, once every 10 h (0–2.2/h). Participants spent 19% of their seated time tilted past 15°. Seventeen participants utilised the tilt feature frequently and spent >20% of the time in multiple positions. The remaining participants sat in a single tilt range for >80% of the time.Conclusions. Given the limited pressure relief compliance, alternative approaches to pressure relief and improved training may be needed for some clients. Wheelchair design and prescriptions may also need to reflect participants' preferences for sitting in small and medium tilts and changing position frequently.

Correlation of Spine Deformity, Lung Function, and Seat Pressure in Spina Bifida

Spinal deformity, a common problem in children with myelodysplasia, is associated with alterations in pulmonary function and sitting balance. Sitting imbalance causes areas of high pressure in patients already at high risk for developing pressure ulcers due to insensate skin. We asked: Does spinal deformity affect pulmonary function tests in children with myelodysplasia? Does the magnitude of spinal curvatures and pelvic obliquity affect seating pressures? Does spinal deformity and seated pressures correlate with a history of pressure ulcers? We retrospectively reviewed 32 patients with myelodysplasia and scoliosis (mean age, 14 years). The mean thoracic scoliosis was 64° with a mean pelvic obliquity of 15°. The mean forced vital capacity was 59% of predicted. The mean of the average and peak seated pressures were 24 and 137 mm Hg, respectively. We examined spinal radiographs, pulmonary function tests, and seated pressure maps and evaluated correlations of spinal deformity measures, pulmonary function, and seated pressures. The thoracic scoliosis inversely correlated with lung volume and weakly related with only the forced midexpiratory volume parameter (R(2) = 31%). The curve magnitude was associated with % seated area with pressures of 38 to 70 mm Hg while lesser degrees of pelvic obliquity were associated with % seating area with pressures of less than 38 mm Hg (R(2) = 25% and 24%, respectively). A history of pressure ulcers did not correlate with any spinal deformity or seated pressure measures. All patients displayed a reduced forced vital capacity, but this reduction was not related to increasing scoliosis. The smaller scoliosis curves and lesser degrees of pelvic obliquity were associated with larger areas of low seated pressures.

Personality and Behavioral Predictors of Pressure Ulcer History

PURPOSE: To assess the relationship of psychological, environmental, and behavioral factors with pressure ulcers (PUs) in persons with spinal cord injury (SCI). METHODS: A total of 1,549 participants from a large rehabilitation hospital in the southeast United States answered questions regarding outcomes after SCI. Variables from each set of factors were entered sequentially into the model: (1) psychological and environmental, and (2) behavioral. RESULTS: Forty-eight percent of participants reported having a PU in the past year. After entering behavioral variables into the model, all environmental and psychological variables became nonsignificant. Odds of having a PU increased 28% with each psychotropic medication taken weekly. Persons who smoked one or more packs of cigarettes daily had 2.82 times the odds of having a PU than persons who did not smoke. Increased hours out of bed were protective against PUs. CONCLUSION: This study demonstrated the importance of health behaviors in the occurrence of PUs after SCI. These health behaviors provide important targets for intervention for health care providers.

Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury

Purpose. The aim of this article is to identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development as perceived by adults with spinal cord injury (SCI).Method. Qualitative in-depth interviews over an 18-month period with 20 adults with spinal injury and a history of pressure ulcers were conducted using narrative and thematic analyses.Results. Eight complexly interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports.Conclusions. Principles pertaining to the relationship between in-context lifestyle and pressure ulcer risk underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. Pressure ulcer prevention for community-dwelling adults with SCI can potentially be enhanced by incorporating principles, such as the decay of prevention behaviors or lifestyle trade-off, that highlight special patterns indicative of elevated risk. The identified principles can be used to theoretically drive future research or to guide innovative lifestyle-focused intervention approaches. Public policies that promote short-term preventive interventions at critical junctures throughout a person's life should be considered.

Association Between Mobility Mode and C-Reactive Protein Levels in Men With Chronic Spinal Cord Injury

Morse LR, Stolzmann K, Nguyen HP, Jain NB, Zayac C, Gagnon D, Tun CG, Garshick E. Association between mobility mode and C-reactive protein levels in men with chronic spinal cord injury. Objective To assess clinical determinants of systemic inflammation in persons with chronic spinal cord injury (SCI). Design Cross-sectional survey. Setting Veterans Affairs medical center. Participants As part of an epidemiologic study assessing SCI-related health conditions, 63 men with chronic SCI provided a blood sample and information regarding locomotive mode and personal habits. Interventions Not applicable. Main Outcome Measure Plasma high-sensitivity C-reactive protein (CRP). Results The mean ± standard deviation age was 56±14y, and participants were assessed 21±13y after injury. Adjusting for heart disease, hypertension, and body mass index (BMI), the mean CRP in 12 motorized wheelchair users (5.11mg/L) was not significantly greater than 23 participants who used a manual wheelchair (2.19mg/L) ( P=.085) but was significantly greater than the 17 who walked with an assistive device (1.41mg/L) ( P=.005) and the 12 who walked independently (1.63mg/L) ( P=.027). CRP was significantly greater in participants with obesity but was not related to age, smoking, or SCI level and severity. CRP was elevated in participants reporting a urinary tract infection (UTI) or pressure ulcer within a year, but adjustment for this did not account for the elevated CRP in motorized wheelchair users. Conclusions These results suggest that CRP in chronic SCI is independently related to locomotive mode, BMI, and a history of pressure ulcers and UTI. It is suggested that future studies in SCI investigate whether modifying these factors influence systemic inflammation and cardiovascular health.

Center-of-Pressure Displacement During Postural Changes in Relation to Pressure Ulcers in Spinal Cord-Injured Patients

To evaluate the center-of-pressure displacement in spinal cord-injured patients, to investigate dynamic sitting stability and its relationship with pressure ulcers. Sixteen spinal cord-injured patients and 18 healthy volunteers were included in the study. For the assessment of dynamic sitting stability, center-of-pressure displacement during maximum unsupported forward, backward, and right- and left-sided trunk leaning were measured with a seat sensor system, which was placed between the subject's buttocks and chair. Center-of-pressure displacements in all directions in spinal-injured patients were smaller than healthy volunteers (P < 0.05). Center-of-pressure displacements for high- and low-thoracic spinal cord-injured patients were not significantly different. History of previous pressure ulcer was not different between high- and low-thoracic spinal cord-injured patients (chi = 0.90, P = 0.62). Mean center-of-pressure displacement during forward and backward leaning were smaller in patients with pressure ulcer history (P = 0.04 and 0.03, respectively). The results of this study suggest that impaired dynamic sitting stability is associated with pressure ulcer development.

The NATVNS Scotland 2006 annual general meeting

To evaluate the predictive power of risk factors for pressure ulcers in adult intensive care patients.A retrospective case-control study was performed utilising a heterogeneous sample group allocated into a case group with pressure ulcers (n = 90) and a control group without pressure ulcers (n = 90). The analysis explored the predictive power of risk factors for pressure ulcers using a hierarchical logistic regression model.The risk factors that predicted pressure ulcers were friction (OR = 5.97), previous history of pressure ulcers (OR = 5.43), prolonged intensive care unit stay (OR = 3.92), dehydration (OR = 3.18), elevated skin temperature by 1–2 °C (OR = 3.12) and treatment of other comorbidities (OR = 2.79).Adult intensive care patients have an increased risk of developing a pressure ulcer. These risk factors are regarded as strong predictors for pressure ulceration. This study advances nursing knowledge in that it investigates additional risk factors for the development of pressure ulcers and it identifies a set of factors that best predict their occurrence, which may contribute to the nurses' diagnostic reasoning in the intensive care unit.