Evaluation of factors affecting pressure ulcers in patients with brain – Spinal injuries: A cross-sectional descriptive study

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MEDICAL SCIENCE l ANALYSIS ARTICLE
Medical Science, 26, e2056 (2022) 1 of 6
Evaluation of factors affecting
pressure ulcers in patients with
brain – Spinal injuries: A cross-
sectional descriptive study
Masoud Hatefi1, Khalil Komlakh2
ABSTRACT
Background: Due to the importance of pressure ulcers (PUs), this study was
performed to determine the status of pressure ulcers in patients admitted to
hospitals in Ilam. Methods: This is a cross-sectional descriptive study that was
conducted (sample size=220). Researchers obtained a list of discharged
patients from hospitals and contacted patients or their companions. The
instruments included a demographic profile form and the Braden Scale for
Predicting PURisks. Data analysis was SPSS ver. 16 software. Results: It
showed most of the patients achieved scores in poor and low risk status. Also,
the overall score for risk of Pus was low, moderate, and high, and very high in
28 (12.7%), 81 (36.7%), 105 (47.7%), and 6 (2.7%) of cases, respectively. The
total mean ± SD of patients with and without Pus was 10.18 ± 0.77 and 13.01 ±
1.40, respectively. Also, there was a significant difference between patients
with and without Pus in terms of the mean ± SD of scores obtained in all items
of this instrument, except friction and shear (P<0.05). Conclusions: Due to the
identification of factors affecting the development of pressure ulcers, it is
necessary to take the necessary interventions to reduce them.
Keywords: Neuroscience, Pressure ulcers, Spinal cord injury
1. INTRODUCTION
Pressure ulcers (PUs) are one of the complications of chronic diseases among
patients who are immobile and despite technological healthcare advances, the
incidence of Pus is high and it is an important challenge and problem in the
health care system (Anthony et al., 2020; Esparza et al., 2021). Pus is actually a
type of tissue damage caused by pressure and can involve the skin, muscle,
soft tissue, cartilage and bone. The prevalence of Pus has increased
worldwide, which doubles the need to pay attention to this group. In this
regard, results of a meta-analysis study on 5973 Iranian patients showed that
the prevalence of Pus was 19% (Soozani & Raei, 2012). The main groups prone
to Pus include in patients, especially surgical patients, seniors, ICU patients,
patients with spinal cord injuries, as well as immobile patients such as stroke
patients (Sallam et al., 2020; Xiao & Peng, 2021).
Medical Science
pISSN 2321–7359; eISSN 2321–7367
To Cite:
Hatefi M, Komlakh K. Evaluation of factors affecting pressure ulcers in
patients with brain – Spinal injuries: A cross-sectional descriptive study.
Medical Science, 2022, 26, e2056.
doi:
Author Affiliation:
1Associate Professor of Neurology, School of Medicine, Emam Khomeini
Hospital, Ilam University of Medical sciences, Ilam, Iran
2Assistant Professor of Neurosurgery, Department of Neurosurgery,
School of Medicine, Imam Hossein Hospital, Shahid Beheshti University
of Medical Sciences, Tehran, Iran
Corresponding author
Assistant Professor of Neurosurgery, Department of Neurosurgery,
School of Medicine, Imam Hossein Hospital,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
Email: khalil.komlakh@yahoo.com
Peer-Review History
Received: 5 January 2022
Reviewed & Revised: 6/January/2022 to 13/February/2022
Accepted: 15 February 2022
Published: 20 February 2022
Peer-review Method
External peer-review was done through double-blind method.
URL: https://www.discoveryjournals.org/medicalscience
This work is licensed under a Creative Commons Attribution 4.0
International License.
Copyright © 2022 Discovery Scientific Society.

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One of the causes of Pus is trauma. Considering the current advanced world and the role of tools and machines in people's lives,
trauma is important pathogens. Traumatic injury is an injury caused by the person him/herself or by a foreign object
(Comeshtappeh & Ganji, 2018). Trauma is the most common cause of death until the fourth decade of life and one of the major
problems of the healthcare system regardless of the economic and social status (Gad & Saber, 2012). The global prevalence of
traumatic events may vary according to geographical population and be affected by factors such as terrorism, war, violence and
natural disasters (Brunello & Davidson, 2021). There are different types of traumas, including vascular trauma, traumatic brain
injury (TBI), vascular trauma, dental trauma, and congenital trauma, each of which has a significant prevalence. In this regard,
results of previous systematic review studies in Iran show that the prevalence of birth trauma in 9 articles published in Ira n is equal
to 2.7% (Shokri & Nayyeri, 2021). Also, the prevalence of lower vascular trauma was 54.8% and the prevalence of subsequent death
in these patients was 12.3% and in a review study by Karimian et al., (2021) on 15 studies entered into the meta -analysis stage,
which indicates the importance of relevant studies in Iran.
Traumatic brain injury (TBI) is a major problem in countries such as Iran. TBI can cause a variety of disorders for patients,
including physical, emotional, cognitive, and behavioral disorders, and can affect and challenge all aspects of a patient's daily life
(Fakharian et al., 2016; Stevens et al., 2013). The prevalence of TBI-related mortality and disability depends on its severity and
mechanism, but prevalence of its adverse outcomes; including severe disability, death, and coma have been reported to be nearly
20% (Bruns & Hauser, 2003). Head traumas include loss of consciousness, skull fracture, brain contusion, post-traumatic syndrome,
subdural hematoma and are one of the important causes of mortality among inpatients (KSJKjon & KSJK, 2020).
Other bedsore risk factors includes stroke, which categorized into cerebrovascular diseases and is one of the main problems
among the seniors and is the second leading cause of death in the world. This disease is one of the common diseases that require
long-term care and can lead to long-term complications such as inactivity and disability (Nakipoğlu-Yüzer et al., 2009; Sire et al.,
2022). The prevalence of stroke complications is reported to be about 40 to 96%, many of which can be prevented if diagnosed early
(Atashi & Mohammadi, 2021). One of these complications is the development of PUs, which can cause various complications and
problems for patients (Huang & Chang, 2021). Considering the importance of preventing the occurrence of Pus in improving the
health status of patients, aim to determine the factors contributing Pus among brain – Spinal injuries patients.
2. METHODS
Study Design
This is a cross-sectional descriptive study that was conducted. The sample size was estimated 220 patients using similar studies.
Researchers obtained a list of discharged patients from hospitals and contacted patients or their companions. They also explained
the study objectives, and obtained their consent to participate in the study. All questionnaires were completed by interviewing the
patient's main caregivers and observing patients (September 2020-December 2020).
Study Population
The present study was performed on TBI patients, including patients with SCI, patients, stroke and head trauma.
Inclusion and Exclusion Criteria
Inclusion Criteria
Inclusion criteria included willingness to participate in the study, participants between the ages of between 18 to 85 years, history of
TBI.
Exclusion Criteria
Exclusion criteria included non-cooperation of the patient or the patient's family, patients weighted <40 kg or >140 kg, suffering
from other chronic diseases except TBI, and the presence of a previous bedsore.
Ethical Approval
The present study was performed after obtaining the ethics code of IR.MEDILAM.REC.1397.132. The necessary training was given
to the participants regarding the research objectives. They were also and the necessary assured about the confidentiality of
information and anonymous reporting of their information.

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Study Tools
The instruments included a demographic profile form and the Braden Scale for Predicting Pressure Ulcer Risks. Braden scale
consists of 6 subsets, including sensory perception, activity, moisture, mobility, friction, and shear. The instrument items are scored
based on a 4-point Likert scale ranging from 1(worst situation) to 4 (normal situation). The possible score range is 6 to 23. The scores
for very high, high, moderate, low, and no risk of PU include 9>, 10-12, 13-14, 15-18, and >19, respectively. Also, the lowest score
means the highest risk of PUsand vice versa (Bergstrom et al., 1998; Lyder et al., 1999).
Statistical Analysis
Data analysis was performed using descriptive statistical tests (including relative frequency, mean) and inferential statistics
(correlation coefficient, logistic regression) in SPSS ver. 16 software.
3. RESULTS
The findings of Table 1 show demographic characteristics of the studied patients. According to the findings, most of the patients
were female, had no history of smoking, were illiterate, had a stroke, had good economic status and were married (Table 1). Also,
mean ± SD of participants' weight was 61.98 ± 15.67 kg. Also, the prevalence of PUs in the studied patients was 25%.
Table 1 Status of demographic variables in patients
Variable
N
%
Sex
Male
144
65.5
Female
76
34.5
Smoking status
Yes
89
40.5
No
131
59.5
Education
illiterate
109
49.5
reading and writing
88
40
Diploma
21
9.5
Masters
2
0.9
Type of disease
SCI
59
26.8
medium
108
49.1
Good
53
24.1
Economic satisfaction
Yes
139
63.2
No
81
36.8
Marital status
Married
159
72.3
Single
61
27.7
Table 2 shows the scoring status of the Braden scale items. Also, most of the patients achieved scores in poor and low risk s tatus.
Also, the overall score for risk of PU was low, moderate, and high, and very high in 28 (12.7%), 81 (36.7%), 105 (47.7%), and 6 (2.7%)
of cases, respectively (Table 2).
Table 2 Frequency distribution (percentage) of Braden tool items in the studied patients
-
Items
very bad
bad
Low risk
Excellent
N (%)
N (%)
N (%)
N (%)
1
Perceptual senses
12(5.5)
61(27.7)
117(53.2)
30(13.6)
2
Skin moisture
22(10)
115(52.3)
67(30.5)
16(7.3)
3
activity
22(10)
107(48.6)
75(34.1)
16(7.3)
4
Movement
142(64.5)
69(31.4)
9(4.1)
0(0)
5
Nutrition
59(26.8)
126(57.3)
33(15)
2(9)
6
Friction and tension
70(31.8)
133(60.5)
17(7.7)
-
Table 3 shows the mean ± SD of status of the Braden scale items in the studied patients. According to the findings, the total
means ± SD of patients with and without PUswas 10.18 ± 0.77 and 13.01 ± 1.40, respectively. Also, there was a significant difference

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Medical Science, 26, e2056 (2022) 4 of 6
between patients with and without PUsin terms of the mean ± SD of scores obtained in all items of this instrument, except friction
and shear (P<0.05) (Table 3). Figure 1 shows the dimensional status of wound areas in non-wound patients.
Table 3 Comparison of M(SD) of score obtained in patients with bed sores and without bed sores
-
Items
No wounds
M(SD)
Haswounds
(SD)
p
F
T
1
Perceptual senses
2.85(0.71)
2.24(0.76)
0.25
1.28
4.67
2
Skin moisture
2.45(0.73)
1.83(0.64)
0.006
7.60
4.71
3
activity
2.50(0.74)
1.78(0.58)
0.005
8.18
5.60
4
Movement
1.45(0.59)
1.10(0.31)
0.000
66.80
3.45
5
Nutrition
1.96(0.65)
1.56(0.64)
0.059
3.61
3.39
6
Friction and
tension
1.78(0.58)
1.64(0.58)
0.33
0.919
1.26
7
Overall score of
the tool
13.01(1.40)
10.18(0.77)
0.002
9.678
11.87
Figure 1 Graph related to the average score obtained by patients with non-wound
4. DISCUSSION
The occurrence of Pus depends on various factors and active prevention is necessary. To reduce the risk of PU, the at-risk
population must be identified and the necessary measures must be taken to prevent the occurrence and spread of this type of ulcers.
It is also necessary to use a tool for systematic and purposeful examination. There are several PU risk assessment scales, one of
which is the Braden scale (Theeranut et al., 2021; Wei et al., 2020). The results showed that the PU was prevalent among 25% of the
studied patients. The PU prevalence of was 9.6%, 14.9%, 18.7%, 8.1%, and 29% in previous studies by Assefa et al., (2021) in
Ethiopia, Bereded et al., (2018), Cox et al., (2011) in the United States (Sample size= 347 patients), González Mendez et al., (2018) in
Spain (Sample size= 335 patients), Gunningberg et al., (2001) in Sweden (Sample size= 101 patients), respectively. Also, relevant
systematic review studies reported different prevalence rates for PU. For example, the above prevalence rate was 11.7%, and 12% in
studies by Shiferaw et al., (2020) in Ethiopia, (Sample size= 1881 patients), and Borojeny et al., (2021) (Sample size= 37971patients).
According to the findings of the present study, the PU prevalence was higher in men than women. Similarly, González Mendez
et al., (2021) showed in a study in Spain that there was a difference between men and women in terms of PU prevalence. Haileyesus
Gedamu et al., (2020) also demonstrated in a study in Ethiopia that the prevalence of PU was 19.6% in men and 13.9% in women,
which is consistent with the results of this study suggesting that there is a difference between men and women in terms of the PU
prevalence. The relationship between age and factors contributing to PU risk was investigated and results showed that the risk of
PU increases with increasing age, which is consistent with the results of a study by Lena Gunningberg et al., (2011) that showed a
2.85
2.45 2.5
1.45
1.96 1.78
0
0.5
1
1.5
2
2.5
3
Perceptual
senses
Skin moisture activity Movement Nutrition Friction and
tension

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higher PU prevalence in older people. Other variables contributing to the PU development is higher weight status, which is
consistent with study by Cristiana Forni et al., (2021)
5. CONCLUSION
Most patients' scores in dimensions Movement, Friction and tension and Nutrition had bad and very bad scores. It is necessary to
take preventive measures to prevent pressure ulcers, especially in these three dimensions. Due to the identification of factors
affecting the development of PUs, it is necessary to take the necessary interventions to reduce them.
Informed Consent
Written informed consent was obtained from eligible patients in their native language (Persian).
Ethical Approval
The Ethics Committee of the Ilam University of Medical Sciences approved (IR.MEDILAM.REC.1397.132(
Authors’ Contribution
MH, KK did study conception, data analysis, and manuscript writing. MH, KK did data collection and manuscript writing. MH, KK
did data collection and manuscript writing. Both authors (MH, KK) contributed to all stages of the article.
Funding
This study has not received any external funding.
Conflict of interests
The authors declare that there are no conflicts of interests.
Data and materials availability
All data associated with this study are present in the paper.
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