Origins and Purpose of the Norton Scale
Named after its creator, Nurse Doreen Norton, the Norton scale was introduced in 1962 as one of the first evidence-based tools for assessing the risk of pressure ulcers in adult patients. At the time, there was a pressing need for a standardized, reliable method to identify individuals most vulnerable to these injuries. The scale addresses this by evaluating five fundamental aspects of a patient's health, allowing healthcare providers to quantify risk and implement preventative measures accordingly. It remains widely used in hospitals, long-term care facilities, and home healthcare settings worldwide.
The Five Key Criteria of the Norton Scale
The scale is based on five specific criteria, with each factor receiving a score from 1 to 4. A lower score on any given item indicates a higher level of impairment and, therefore, a greater risk of developing a pressure ulcer.
1. Physical Condition
This category assesses the patient's general health, taking into account any medical conditions, injuries, or overall frailty. Scores range from Good (4 points) to Very Bad (1 point). For older adults, this is particularly relevant as comorbidities and a general decline in health can increase vulnerability.
2. Mental Condition
This criterion evaluates a patient's cognitive status and level of awareness. It considers their ability to understand, respond to, and participate in their own care. The scoring options are Alert (4), Apathetic (3), Confused (2), and Stupor (1). A patient who is confused or apathetic may not be able to communicate discomfort or reposition themselves, dramatically increasing risk.
3. Activity
This factor measures a patient's overall activity level, not just their ability to walk. It considers how often and how much a person moves. The categories include Ambulant (4), Walks with Help (3), Chairbound (2), and Bedfast (1). A patient who is chairbound or bedfast is at significantly higher risk due to prolonged pressure on specific areas.
4. Mobility
While related to activity, this criterion focuses specifically on the patient's ability to change and control their body position. It assesses the range of movement and the ability to reposition independently. The scoring options are Full (4), Slightly Impaired (3), Very Limited (2), and Immobile (1). A patient who is immobile or very limited cannot relieve pressure, even if they are conscious.
5. Incontinence
This assesses the patient's continence status, as moisture from urine or feces is a major contributing factor to skin breakdown. Skin that is constantly wet is more susceptible to damage. The options are Not (4), Occasional (3), Usually/Urine (2), and Doubly/Urine and Fecal (1). Proper management of incontinence is a key component of a pressure ulcer prevention plan.
Interpreting Norton Scale Scores
The scores from the five categories are added together to produce a total score ranging from 5 to 20. The higher the score, the lower the risk of developing a pressure ulcer. Conversely, a lower total score indicates a higher level of risk. The interpretation is typically divided into risk levels:
- Low Risk: A score greater than 16 (or some scales use >18) indicates a low risk.
- Medium/Moderate Risk: A score between 14 and 16 (or 14-18) indicates a moderate risk.
- High Risk: A score of 13 or below is generally considered high risk.
Norton vs. Braden Scale: A Comparison
While the Norton scale is a long-standing and respected tool, the Braden scale is another widely used assessment. Here is a comparison of their key features:
| Feature | Norton Scale | Braden Scale |
|---|---|---|
| Year Developed | 1962 | 1987 |
| Number of Subscales | 5 (Physical Condition, Mental Condition, Activity, Mobility, Incontinence) | 6 (Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear) |
| Scoring Range | 5–20 | 6–23 |
| Key Differences | Focuses on basic clinical observations. Considered simpler and quicker to use. | Includes more nuanced factors like nutrition and friction/shear. Often seen as more comprehensive. |
| Primary Use | General risk assessment, especially in geriatric settings. | Detailed risk assessment, widely used in acute care hospitals. |
Implementing Preventive Care
The value of the Norton scale lies in its ability to quickly and reliably identify at-risk patients, triggering timely and targeted interventions. A care plan for a patient with a low Norton score (high risk) might include the following measures:
- Repositioning Schedule: Establishing a frequent and regular schedule for changing the patient's position to relieve pressure on bony areas. This might be every two hours for bedfast individuals.
- Skin Inspection: Conducting daily, thorough skin assessments to look for any signs of redness, skin breakdown, or other issues.
- Pressure-Relieving Surfaces: Utilizing specialized mattresses, cushions, or beds designed to distribute pressure more evenly and reduce the risk of injury.
- Incontinence Management: Implementing a strict incontinence care plan, which may include frequent checks, timely changes, and the use of skin barrier creams to protect against moisture damage.
- Encouraging Activity: For those who are chairbound or have limited mobility, encouraging small movements and providing assistance with transfers to promote circulation.
Guiding Proactive Senior Care
The Norton scale's application is not limited to inpatient settings. For seniors aging at home or in assisted living, it can be a useful tool for family caregivers or visiting nurses. A low score can signal a need for increased support, from hiring a professional caregiver to acquiring specialized equipment. Its simplicity makes it easy to understand and integrate into a routine care management plan. Regular reassessment is key, especially after a significant health change, as a patient's risk level can change over time. By using this tool, caregivers and families can take proactive steps to prevent pressure ulcers, which are not only painful and difficult to heal but can also lead to more serious complications.
Conclusion
In summary, what is the Norton scale used for? It is a crucial, easy-to-use tool for assessing a patient's risk of pressure ulcers by evaluating five key factors. This assessment informs and guides the development of proactive, preventive care plans. By understanding and utilizing the Norton scale, healthcare professionals, caregivers, and families can significantly improve patient safety and comfort, particularly for vulnerable older adults.
For more information on pressure ulcer prevention strategies and tools, the Agency for Healthcare Research and Quality is an authoritative source.
