Norton Measure

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Tool Description

  • The first pressure ulcer risk assessment that was developed and was intended for use with a geriatric hospital population.
  • The measure, based on the researcher’s clinical expertise, considers five domains relevant to skin condition:

(1) Physical condition
(2) Mental condition
(3) Activity
(4) Mobility
(5) Incontinence
They are measured on an ordinal scale from 1 to 4.

ICF Domain:

Body Function – Subcategory: Functions of the Skin.

Number of Items:


Brief Instructions for Administration & Scoring


  • Raters indicate client status based on personal observation or chart review.
  • Scales are scored on a domain specific ordinal scale from 1 to 4.
  • This tool takes 5-10 minutes to administer.

Equipment: None.


  • Though each item comes with standardized descriptive criteria on the score sheet, descriptors for item scoring are very brief.
  • Items are measured on an ordinal scale from 1 to 4.
  • A summary score ranging from 5 – 20 is calculated.


MCID: not established for SCI
SEM: not established for SCI
MDC: not established for SCI

  • Higher scores equal better prognosis.
  • A cut-off score of 14 has been suggested to identify individuals at risk for developing pressure sores. However, there is currently no research evidence to support the use of this value.
  • No normative data has been established for the SCI population.
  • Published data for the SCI population is available for comparison (see the Interpretability section of the Study Details sheet).



Training Required:

None but expertise in pressure ulcer risk assessment is needed.


Can be found online at:

Clinical Considerations

  • The Norton is a commonly used scale with a variety of populations. However, it omits items previously found to be important predictors of pressure ulcer development for people with SCI such as pulmonary disease, serum creatinine, extent of paralysis, severe spasticity, age, tobacco use/smoking, disease, cardiac disease, renal disease, and living in a nursing home or hospital. The reliability of the scale has not been demonstrated with the SCI population.  The Norton was the worst measure for predicting stage and number of pressure ulcers in individuals with SCI during the first 30 days of admission compared to the SCIPUS, SCUIPUS-A, Braden, Gosnell and Abruzzese.
  • The Norton scale is quick to administer and easy to score. There is no patient burden.

Measurement Property Summary

# of studies reporting psychometric properties: 3


No values were reported for the reliability of the Norton measure for the SCI population.


  • The Norton measure was 60.8% accurate in predicting pressure ulcer development; it has a sensitivity of 5.8% and a specificity of 95.6%.
  • The Norton measure has a Low correlation with the stage of the first pressure ulcer (Spearman’s r=-0.192) and the number of ulcers developed (Spearman’s r=-0.197).
  • The Norton measure has Moderate correlations with other measures of pressure ulcers (Braden and Waterlow Scales).
  • ROC analysis for the Norton measure yielded an AUC of 72 (95% CI: 64-81).

[Salzberg et al. 1999, Wellard 2000, Ash 2002]


No values were reported for the responsiveness of the Norton Measure for the SCI population at this time.

Floor/ceiling effect:

  • 86% of patients are at no risk, 8% are at risk and 2% are at high risk when the risk ratings from Norton et al. 1962 are used.

[Wellard 2000]


Dr. Vanessa Noonan, John Zhu

Date Last Updated:

August 22, 2020

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Download Worksheet:

Worksheet Document




  • Though each item comes with standardized descriptive criteria on the score sheet, descriptors for item scoring are very brief.
  • Items are measured on an ordinal scale from 1 to 4.
  • A summary score ranging from 5 – 20 is calculated.

Equipment Needed



Agency for Health Care Policy and Research (AHCPR). Panel on the prediction and prevention of pressure ulcers in adults. Pressure Ulcers in Adults: Prediction and Prevention. In Clinical Practice Guideline No. 3. AHCPR Publication No. 92-0047. Rockville MD: AHCPR; 1992.

Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. J Clin Nurs 2002;11:470-478.

Norton D, McLaren R, Exton-Smith AN. An Investigation of Geriatric Nursing Problems in Hospitals. London: National Corporation for the Care of Old People;1962.

Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.

Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.

Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.