Nursing Diagnosis and Nursing Intervention

10 Causes of Pressure Sores

Braden and Bergstrom (2000) developed a scheme for describing the risk factors for the occurrence of pressure sores. There are two main things that relate to the risk of pressure sores, the pressure factor and tissue tolerance. Factors that influence the duration and intensity of pressure on the protruding bone is immobility, inactivity, and decreased sensory perception. While the factors that affect tissue tolerance divided into two factors : extrinsic and intrinsic factors.

1. Intrinsic factors: aging (weak cell regeneration), number of diseases that cause such as diabetes, nutritional status, underweight or overweight, anemia, hypoalbuminemia, neurological diseases and diseases that damage the blood vessels, state of hydration / body fluids.

2. Extrinsic factors: Cleanliness bed, weaving tools are matted and dirty, or medical equipment that causes sufferers fixed on a certain attitude, a poor Sitting, improper position, position changes less. Below is an explanation of each of these factors:

Cleanliness of the beds, weaving tools are matted and dirty, or medical equipment that causes sufferers fixed on a certain attitude, a poor Sitting, improper position, position changes less. Below is an explanation of each of these factors:

1. Mobility and activity
Mobility is the ability to change and control the position of the body, while the activity is the ability to move. Patients who continue to lie in bed without being able to change the position of high risk for developing pressure sores. Immobility is the most significant factor in the incidence of pressure sores.

2) Decrease in sensory perception
Patients with decreased sensory perception of decreased sensation to feel the pain caused by pressure on the protruding bone. When this happens in a long duration, the patient will be susceptible to pressure sores.

3. Humidity
Moisture caused by incontinence can result in tissue maceration on the skins. Tissue maceration experience will be susceptible to erosion. In addition it also resulted in moisture prone skin friction and tearing tissue (shear). Faecal incontinence is more significant in the development of pressure sores than urinary incontinence because the bacteria and enzymes in the stool can damage the surface of the skin.

4. Tearing energy (shear)
A mechanical force that stretch and tear the tissue, blood vessels and the deeper tissue structures adjacent to the protruding bone. The most common example of this is the force that ripped when the patient is positioned in a semi-Fowler position in excess of 30 degrees. In this position, the patient can be dropped down, thus resulting in the bones to move downward, but her skin is still lagging. This can lead to occlusion of blood vessels, as well as damage to internal tissue such as muscle, but caused little damage to the skin surface.

5. Friction
Friction occurs when two surfaces move in the opposite direction. Friction can cause abrasion and damage the surface of the skin epidermis. Friction could occur when changing bed linen patients who are not careful.

6. Nutrition
Hypoalbuminemia, weight loss, and malnutrition is generally identified as a predisposing factor for the occurrence of pressure sores. According to research Guenter (2000) stage three and four of the cuts hit the parents associated with weight loss, low albumin levels, and inadequate food intake.

7. Age
Older patients have a high risk of developing pressure sores because the skin and tissue will change with aging. Aging result in muscle loss, decreased serum albumin levels, decreased inflammatory response, decreased skin elasticity, as well as decrease the cohesion between the epidermis and dermis. This change combined with other aging factors will make the skin become less tolerance to pressure, friction, and energy tearing.

8. Arteriolar pressure is low
Arteriolar pressure is low will reduce skin tolerance to pressure so that the low pressure application is able to cause tissue to ischemia. Studies conducted by Nancy Bergstrom (1992) found that the systolic pressure and low diastolic pressure contribute to the development of pressure sores.

9. Emotional stress
Depression and chronic emotional stress such as in psychiatric patients is also a risk factor for the development of pressure sores.

10. Skin temperature
According to the research Sugama (1992) an increase in temperature is a significant factor in the risk of pressure sores. According to the research, other important factors that also influence the risk of pressure sores is the interface pressure). Interfacial pressure is force per unit area between the body surface of the mat. If the interfacial tension is greater than the average capillary pressure, the capillaries will easily collapse, the area becomes easier to ischemia and necrotic. Average capillary pressure is about 32 mmHg. According to research Sugama (2000) and Suriadi (2003) high-pressure interface is a significant factor for the development of pressure sores. Interface pressure is measured by placing a pressure gauge interface (pad pressure evaluator) between the depressed area with a mattress.

Source :

Nursing Diagnosis

Nursing Diagnosis


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