Other factors
Many other host factors have also been evaluated in an attempt to define their role in pressure ulcer development. Among the demographic factors identified in some studies are older age, white race, and male gender. Specific diagnoses that have been associated with ulcer development include the presence of dry skin, recent lower extremity fractures, diabetes, and cardiovascular disease.

Identification of patients at risk
Knowledge of factors contributing to the pathogenesis of pressure ulcers allows the identification of patients at risk for ulcer development. Preventive interventions may then be targeted to those specific patients. Assessment of risk for pressure ulcer development is not a one time activity. Patients should be reassessed periodically, particularly when there is a change in health status.
The Norton scale (table 1)
The Norton scale uses a 1 to 4 scoring system in rating patients in each of five subscales: physical condition; mental condition; activity; mobility; and incontinence. A score less than 14 indicates a high-risk of pressure ulcer development.

*Calculated as the sum of the scores in all five areas.
*A Score less than 14 indicates a high risk of pressure ulcer development.
*Adapted from Norton, D, Decubitus 1989;2:24.

Prediction Rules for Pressure Ulcer Development : Norton Scale*
Physical Condition	4 = Good 3 = Fair 2 = Poor 1 = very bad
Mental Condition	4 = Alert 3 = Apathetic 2 = Confused 1 = Stupor
Activity	4 = Ambulant 3 = Walk/help 2 = Chair bound 1 = Bed
Mobility	4 = Full 3 = Slightly limited 2 = Very limited 1 = Immobile
Incontinent	4 = Not 3 = Occasional 2 = Usually /urine 1 = Doubly

Staging
A number of staging systems have been developed to describe the extent of pressure ulcers. The most commonly used system, proposed by the
National Pressure Ulcer Advisory Panel, is described as follows:
Stage 1 – Stage 1 is characterized by an observable pressure-related alteration of intact skin which, when compared to an adjacent or opposite site area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness); tissue consistency (firm or boggy feel); and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin; in darker skin tones the ulcer may appear with persistent red, blue, or purple hues.
Stage 2 – Stage 2 is characterized by a partial thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage 3 – Stage 3 is characterized by a full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through the underlying fascia. The ulcer presents clinically as a deep crater with or without under-mining of the adjacent tissue.
Stage 4 – Stage 4 is characterized by a full thickness skin loss with extensive destruction, tissue necrosis, or damage to the muscle, bone, or supporting structures.
Healing scales
Healing ulcers do not progress serially from one stage to the next lowest. Instead, they heal through a process which includes granulation, wound contraction, reepithelialization, and scar formation. The healing process is better described by scales that capture changes in surface area, extent of necrotic tissue and exudate, and the presence of granulation tissue. One such staging system is presented in Table-2.

Stage	Description
0	Normal skin, but at risk
1	Skin completely closed.May lack pigmentatation or may be reddened
2	Wound edges and center are filled in Surrounding tissues are intact and not reddened
3	Wound bed filling with pink granulation tissue Slough present Free of necrotic tissue Minimum drainage and odor
4	Moderate to minimal granulation tissue Slough and minimal necrotic tissue Moderate drainage and odor
5	Presence of heavy drainage and odor, eschar, and slough Surrounding skin reddened or discolored
6	Breaks in skin around primary ulcer Purulent drainage, foul odor, necrotic tissue and/or eschar May have septic symptoms