Norton Scale

Key Takeaways

Assesses five factors: physical condition, mental state, activity, mobility, incontinence.

Scores below 14 indicate high pressure ulcer risk requiring immediate intervention.

The most widely used standardised risk assessment tool since 1962.

Regular rescreening during hospitalisation prevents hospital-acquired pressure injuries.

Pressure ulcers (also called bed sores or pressure injuries) represent a serious healthcare challenge, affecting patient outcomes and increasing care costs. The Norton Scale is the gold-standard clinical assessment tool for identifying patients at risk of developing these wounds before they occur. Developed by nurse researcher Doreen Norton in 1962, the Norton Scale evaluates five critical factors to generate a risk score that guides preventive care planning.

This downloadable template provides a practical, evidence-based form that healthcare teams can integrate into their routine patient assessments. Whether you’re managing long-term care residents, hospital inpatients, or community patients with reduced mobility, the Norton Scale offers a systematic way to standardise risk evaluation and document clinical decision-making. The following guide explains what the Norton Scale is, how to use it, and why it remains essential for patient safety in clinical practice.

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What is the Norton Scale?

The Norton Scale is a standardised risk assessment tool designed to identify patients at risk of developing pressure ulcers. Created by Doreen Norton and her team at a London hospital in 1962, it was the first validated pressure sore risk assessment scale ever developed. Today, it remains one of the most widely recognised and used tools in healthcare settings worldwide, with research examining the inter-rater reliability of the Norton Scale to ensure consistent application across different clinicians.

, from acute hospitals to long-term care facilities.

The tool evaluates five clinical domains: physical condition, mental state, activity level, mobility, and continence status. Each domain is scored on a numeric scale, and these scores are added together to produce a total pressure ulcer risk assessment score. This total tells clinicians how vulnerable a patient is to developing a pressure injury-essential information for planning preventive care strategies. Recent research has expanded understanding of how the Norton Scale predicts diverse clinical outcomes including healthcare utilization following acute medical events.

From a legal and regulatory perspective, the Norton Scale serves an important compliance function. The Agency for Healthcare Research and Quality (AHRQ) identifies pressure ulcer prevention as a core patient safety priority, and documenting standardised risk assessment is a requirement under CMS quality measures and Joint Commission standards. Using a validated tool like the Norton Scale demonstrates that your practice is employing evidence-based clinical protocols and supports your compliance documentation in audit and regulatory reviews.

The scale is particularly valuable in geriatric and long-term care settings, where pressure injury risk is highest. Older adults, patients with reduced mobility, those with impaired consciousness, and individuals with incontinence are all at elevated risk. By systematically assessing these factors, the Norton Scale enables early identification and timely intervention before pressure damage occurs.

How to Use the Norton Scale

The Norton Scale uses a straightforward five-step assessment process that takes 5-10 minutes to complete. Each domain is evaluated against specific clinical criteria, scored on a numeric scale, and recorded on the assessment form within your patient record. Here’s how to systematically use the tool in your clinical practice:

1. Assess physical condition. Evaluate the patient’s general health status by observing their skin condition, nutritional state, presence of acute illness, and overall vitality. Score from 1 (poor) to 4 (good). Patients with poor nutrition, fever, or severe illness score lower and carry higher risk.
2. Evaluate mental state. Assess the patient’s orientation and responsiveness. Can they understand and respond to your clinical instructions? Score from 1 (unconscious/no response) to 4 (alert and oriented). A confused or apathetic patient cannot communicate skin discomfort or pressure sensations, increasing injury risk.
3. Document activity level. Record how much time the patient spends in bed, chair, or moving around. Immobilised patients confined to bed score 1 (bedfast), while independently mobile patients score 4. Activity drives blood flow to at-risk areas; immobility concentrates pressure.
4. Rate mobility status. Assess the patient’s ability to change position or shift their weight without assistance. Can they turn in bed? Lift themselves from a chair? Patients who cannot move independently score lower. Restricted movement means prolonged pressure on vulnerable skin surfaces.
5. Determine continence status. Note whether the patient maintains continence, is occasionally incontinent, usually incontinent, or doubly incontinent (both urine and stool). Incontinence exposes skin to moisture and caustic substances, increasing breakdown risk. Score from 1 (doubly incontinent) to 4 (continent).

After scoring all five domains, add the individual scores to obtain the total risk score. A score of 14 or below indicates high risk; scores 15-18 indicate moderate risk; scores 19-20 indicate minimal risk. Document the total score, the date of assessment, and the specific scores for each domain in the patient’s clinical record. This structured documentation creates an audit trail and supports clinical decision-making about preventive care escalation. A clinical trial of Norton Scale assessment demonstrated benefits when incorporating the tool into care planning.

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Who is the Norton Scale Helpful For?

The Norton Scale is a universal tool applicable across multiple healthcare disciplines and care settings. Any practice managing patients with reduced mobility, advanced age, or chronic illness benefits from systematic pressure ulcer risk assessment.

Long-term care facilities and residential aged care homes use the Norton Scale during initial admission assessment and then regularly throughout the patient’s stay. Older adults in these settings have multiple pressure ulcer risk factors-age-related skin changes, reduced activity, incontinence-making systematic screening essential. Studies have found that low admission Norton scale scores predict falls and other adverse outcomes in elderly patients with hip fractures.

-making systematic screening essential.

Acute hospital teams, including medical-surgical units, critical care departments, and emergency services, employ the Norton Scale for inpatient screening. Hospitalised patients experience sudden loss of mobility, prolonged bed rest during recovery, and altered consciousness due to medication or illness-all factors that increase pressure injury risk during relatively short admission periods.

Community and home care services integrate the Norton Scale into initial home visit assessments. Patients recovering from surgery, managing chronic neurological conditions like stroke or Parkinson’s disease, or cared for by family members at home all benefit from standardised risk evaluation and documented prevention planning.

Allied health and rehabilitation settings, including physiotherapy clinics and occupational therapy services, use the scale when working with patients with reduced mobility or neurological conditions. Wound care specialists apply the Norton Scale to prevent recurrence of healed pressure injuries. Occupational health practitioners and disability support coordinators use it for patients with long-term mobility restrictions or spinal cord injuries.

Benefits of Using the Norton Scale

Standardised assessment ensures consistency. The Norton Scale removes guesswork from risk evaluation. Rather than relying on clinician intuition-which varies widely-the scale applies the same criteria to every patient, ensuring all team members identify risk in the same way. This consistency is critical in multi-clinician settings like hospitals and care homes.

Early identification prevents costly complications. A pressure ulcer that develops costs significantly more to treat than prevention protocols cost to implement. By identifying high-risk patients early, you trigger timely interventions-pressure-relieving surfaces, positioning protocols, nutritional support, skin inspection-before tissue damage occurs. This reduces hospital readmissions, extends patient independence, and improves quality of life.

Documentation supports regulatory compliance. Health regulators, insurers, and accreditation bodies expect evidence that your practice uses validated assessment tools. The Norton Scale’s documented history-65+ years of clinical use and peer-reviewed research-provides that evidence. Recorded assessments demonstrate your compliance with quality standards during audits and investigations.

Communication with the care team improves. A numerical risk score provides a universal language for clinical communication using team collaboration tools. Rather than describing a patient as “at risk,” you state “Norton Scale score 12”-a fact that all team members understand immediately and that drives specific care protocols. This clarity reduces communication gaps and missed interventions.

Risk monitoring becomes systematic. The Norton Scale is not a one-time assessment; it’s rescreened when patient status changes-after surgery, during illness episodes, following changes in mobility. This systematic rescreening catches risk escalation and allows preventive intensity to match current vulnerability. Documentation of serial scores shows trend data essential for clinical decision-making and audit review.

Pressure Ulcer Prevention Strategies Based on Risk Scores

Norton Scale risk scores guide your prevention strategy. High-risk patients (scores 14 and below) require intensive preventive protocols; moderate-risk patients (15-18) need standard precautions; low-risk patients (19-20) need routine monitoring. This risk-stratified approach allocates resources efficiently while protecting vulnerable patients.

For high-risk patients (score ≤14): Provide pressure-relieving support surfaces (foam mattresses, alternating air mattresses, gel overlays-not ordinary hospital beds). Establish two-hourly repositioning schedules and document adherence. Inspect skin daily, particularly over bony prominences (heels, sacrum, hips). Ensure adequate nutrition and hydration. Use incontinence care protocols (protective creams, scheduled toileting). Consider anti-embolic stockings if mobility is severely restricted.

For moderate-risk patients (score 15-18): Use standard hospital mattresses or foam overlays. Reposition every 3-4 hours during waking hours. Conduct skin inspections during routine care. Reinforce nutrition and hydration. Address incontinence promptly. Encourage movement and activity within the patient’s capability.

For all risk levels, educate patients and families about pressure injury risk. Teach family carers how to check skin, reposition, and recognise early warning signs (redness that doesn’t blanch, broken skin, swelling). Mobility and activity prevent pressure ulcers-every increase in movement, no matter how small, reduces risk. Equipment matters, but human care and vigilance matter more.

Documentation and Regulatory Requirements for Pressure Injury Assessment

Documenting the Norton Scale assessment creates a critical record for compliance, clinical continuity, and defensive documentation. Your record must include: the date and time of assessment, the individual scores for each of the five domains, the total risk score, the clinician’s name and role, and the planned preventive interventions. This structured documentation demonstrates that you applied a validated, evidence-based tool and made documented care decisions based on objective findings.

Regulatory bodies including the National Institute for Health and Care Excellence (NICE) and the National Pressure Injury Advisory Panel (NPIAP) recommend routine documented pressure ulcer risk screening for all patients in hospital, long-term care, and community settings. CMS quality indicators for hospital-acquired conditions and care home quality standards specifically reference pressure injury prevention. Using the Norton Scale and recording assessments demonstrates compliance with these national standards.

When using digital assessment forms, ensure your system captures all five domain scores, calculates the total automatically, and flags high-risk patients for clinician awareness. Digital documentation provides audit trails, enables trend analysis over time, and integrates assessments into care planning workflows. When a pressure injury does occur, documented Norton Scale assessments show regulators that you applied current best practice and identified risk appropriately-strengthening your defence against negligence claims and demonstrating due diligence during incident investigations.

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Implementing the Norton Scale in Your Practice

The Norton Scale remains the most widely used pressure ulcer risk assessment tool because it works. Developed over 60 years ago by a nurse researcher determined to prevent suffering, it has been validated across thousands of patients and healthcare settings. Using this evidence-based tool signals to patients, families, and regulators that your practice prioritises safety and applies scientific rigour to clinical care.

Implementation requires three elements: training clinicians on accurate scoring, integrating the assessment into routine workflows (admission, care reviews, discharge), and documenting results systematically. Whether you use the downloadable PDF template provided above or integrate it into digital patient records, the goal remains the same-identify vulnerability before pressure damage occurs and implement prevention strategies tailored to each patient’s risk level. Starting with a validated tool is the first step toward preventing hospital-acquired pressure injuries and improving patient outcomes.

Frequently Asked Questions