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Printed on 7/20/2026
For informational purposes only. This is not medical advice.
The Norton Scale is a bedside pressure injury risk screening tool that assigns 1-4 points across five domains. Total scores range from 5 to 20, with lower scores indicating higher risk and need for stronger prevention protocols.
Formula: Norton = sum of 5 domains scored 1-4 each (total 5-20).
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Score the patient on five domains, each rated 1–4: (1) Physical condition — 4=Good (minimal health problems); 3=Fair (minor illness, stable chronic disease); 2=Poor (serious illness, recent surgery); 1=Very bad (critically ill, terminal). (2) Mental condition — 4=Alert (fully oriented); 3=Apathetic (lethargic, responds slowly); 2=Confused (disoriented, inappropriate responses); 1=Stuporous (minimal response to stimuli, unresponsive). (3) Activity — 4=Ambulant (walks independently or with minimal assistance); 3=Walks with help (needs assistance of one person); 2=Chairbound (can sit in chair but not walk); 1=Bedfast (confined to bed). (4) Mobility — 4=Full (full voluntary movement of all limbs); 3=Slightly limited (some restriction in limb movement); 2=Very limited (moves limbs slightly, does not reposition); 1=Immobile (cannot reposition at all, fully dependent). (5) Incontinence — 4=None (continent of urine and stool); 3=Occasional (incontinent once or twice in 24 hours); 2=Usually urinary (incontinent of urine most of the time, continent of stool); 1=Double (incontinent of both urine and stool).
Add the scores from all five domains. The total Norton Scale score ranges from 5 (highest risk — immobile, bedfast, incontinent, confused, very bad physical condition) to 20 (lowest risk — fully ambulant, alert, continent, and in good physical condition). The score is inversely related to risk: lower score = higher risk. Note that the Norton Scale was designed so that ANY score can be clinically actionable; do not wait for a score to cross a threshold before initiating prevention measures for a patient with visible risk factors. Score the patient at their current state, not at their best possible state — a patient who is 'normally alert at home' but currently confused on the hospital ward should be scored as confused.
Interpret the total score using standard Norton thresholds: 14–20 = No or low risk — standard repositioning schedule (every 2–4 hours if bedbound), routine skin inspection at each turn, standard mattress. 12–13 = At risk — initiate pressure injury prevention protocol: 2-hourly repositioning minimum, pressure-redistributing foam mattress or overlay, intensive skin and moisture care, nutritional assessment, heels offloaded when in bed. Below 12 = High risk — escalate to reactive pressure-redistributing mattress (alternating-pressure air mattress), hourly repositioning monitoring, specialist tissue viability nurse (TVN/WOCN) consultation, nutritional support (dietitian referral), skin barrier creams for incontinence-associated dermatitis. Below 9 = Very high risk — consider highest-specification pressure-relief surface (air-fluidized or low-air-loss mattress), repositioning documentation chart at bedside, wound prevention bundle activation. Reassess the Norton Score at a minimum: within 24 hours of admission, after any clinical deterioration, and at weekly intervals for at-risk patients.
Hospital nurses, charge nurses, wound care nurses
The Norton Scale is one of the most widely used bedside pressure injury screening tools in hospital settings. Completing a Norton assessment within 6–8 hours of hospital admission (required by Joint Commission and CMS nursing standards) identifies patients who need immediate prevention interventions before skin breakdown can occur. Hospital-acquired pressure injuries (HAPIs) are a CMS 'never event' — meaning Medicare does not reimburse for their treatment, and they are publicly reported quality metrics. A systematic Norton Scale screening protocol at admission, with risk-matched protocol activation, is a key component of hospital pressure injury prevention programs. Norton scores should be documented in the EHR and trigger automated nursing care plan entries in Epic or Cerner when score is below 14.
Nursing home nurses, long-term care directors of nursing, MDS coordinators
The Norton Scale is particularly appropriate for nursing home and long-term care residents, where the population has high baseline pressure injury risk due to chronic immobility, incontinence, and nutritional deficiencies. MDS (Minimum Data Set) 3.0 requires assessment of pressure injury risk in all nursing home residents; Norton Scale provides a structured, documentable approach. Norton-based risk stratification guides equipment allocation: standard hospital beds for low-risk residents, pressure-reducing foam or gel mattresses for at-risk residents, and alternating-pressure systems for high-risk. Weekly Norton reassessment for at-risk residents documents ongoing risk monitoring required by federal long-term care regulations (42 CFR §483.25).
ICU nurses, critical care physicians, critical care resource nurses
ICU patients have the highest pressure injury risk in the hospital: sedation and paralytic agents eliminate the spontaneous repositioning that prevents ischemia; vasopressors cause peripheral vasoconstriction that reduces skin perfusion; hemodynamic instability limits the frequency of repositioning; devices (ET tubes, NG tubes, oxygen masks) create medical device-related pressure injuries (MDRPIs). In ICU settings, the Norton Score at admission typically ranges from 5–10, indicating very high risk requiring the highest-specification prevention bundles: air-fluidized or low-air-loss beds, heel protectors, oral/nasal device rotation protocols, and hourly skin inspection. Norton reassessment after each hemodynamic deterioration or clinical status change tracks risk evolution during ICU admission.
Surgical ward nurses, perioperative nurses, surgical team coordinators
Surgical patients are at elevated pressure injury risk due to prolonged immobility during and after surgery, post-operative sedation and analgesia impairing spontaneous repositioning, blood loss and hemodynamic changes reducing skin perfusion, and incontinence common in the early post-operative period. Norton Scale completion in the post-operative recovery room identifies patients who need enhanced prevention before transfer to the surgical ward. For surgeries lasting over 2 hours, perioperative pressure injury prevention (specialized operating table padding, heel offloading, intraoperative repositioning for prone or lateral cases) should be documented alongside post-operative Norton assessment. Total hip and knee replacement patients are particularly high-risk for heel pressure injuries.
District nurses, community health nurses, home health aides, case managers
Community and home health nurses use the Norton Scale to assess pressure injury risk in housebound and bedbound patients receiving care at home. This population often has very limited formal monitoring — a weekly or biweekly nursing visit may be the only professional skin assessment available. Norton scores guide the intensity of carer education: family and paid carers are taught repositioning schedules matched to the patient's Norton score, incontinence pad types and change frequency, skin barrier product use, and warning signs that require urgent nursing contact. Norton score also informs recommendations for community equipment loans: pressure-reducing mattresses and cushions are available through NHS or equivalent programmes for patients meeting threshold scores.
Both the Norton Scale and the Braden Scale are validated pressure injury risk assessment tools with comparable predictive validity (AUC approximately 0.75–0.85 in meta-analyses). Facilities should choose one and use it consistently across all units to enable facility-wide tracking, quality metric comparison, and staff familiarity. Mixing tools creates confusion about risk thresholds and intervention protocols. The Norton Scale is simpler (5 domains vs. Braden's 6) and slightly quicker to complete; Braden has more detail in the moisture and nutrition domains. For most acute hospital and nursing home settings, either tool is appropriate.
The Norton Scale includes physical condition but does not have a dedicated nutrition domain (unlike Braden, which has a specific nutrition item). In clinical practice, nutritional status is one of the strongest modifiable predictors of pressure injury development and healing. For any patient with Norton score below 14, formal nutritional screening (using MUST or MNA-SF) should be completed and dietitian consultation obtained for protein-calorie supplementation in undernourished patients. Protein intake ≥1.2–1.5 g/kg/day and adequate caloric intake are central to pressure injury prevention in high-risk patients.
Recording the Norton total score (e.g., 'Norton 11') without documenting the prevention protocol activated provides inadequate care planning. Best practice documentation includes: the score, the specific risk tier triggered, the prevention interventions activated (repositioning frequency, surface type, skin care protocol), the scheduled reassessment date, and who was responsible for educating the patient and family. This level of documentation is required for Joint Commission standards, CMS survey compliance, and medicolegal protection if a pressure injury develops.
Pressure combined with moisture (from incontinence, perspiration, or wound drainage) causes maceration that dramatically increases pressure injury risk — skin saturated with urine or stool is far more vulnerable to friction, shear, and pressure damage than dry skin. Patients with incontinence scores of 1 or 2 on the Norton Scale need dedicated moisture management: absorbent briefs with regular changes, pH-balanced cleansing products, and protective skin barrier creams (zinc oxide or dimethicone-based products) applied after each incontinence episode. Incontinence-associated dermatitis (IAD) should be distinguished from pressure injuries in documentation.
The Norton Scale assesses traditional pressure injuries from body weight on bony prominences. Medical device-related pressure injuries (MDRPIs) — from oxygen masks, ET tubes, NG tubes, foley catheters, splints, and monitoring leads — require separate prevention protocols and documentation. MDRPIs are now the second most common type of hospital-acquired pressure injury. In ICU patients in particular, device rotation schedules, padding between device and skin, and regular skin inspection under all devices must be documented separately from the Norton-driven repositioning schedule.
Pressure injury risk is dynamic and can change rapidly with clinical status changes: a new stroke, sedation initiation, vasopressor start, temperature spike, or fluid resuscitation can dramatically increase pressure injury risk within hours. A patient who scored 15 (low risk) yesterday can score 8 (very high risk) today after a clinical deterioration event. Build triggers for Norton reassessment into clinical deterioration protocols: RRT activation, ICU transfer, new restraint application, and major medication changes (opioids, sedatives, vasopressors) should each automatically trigger Norton reassessment.
The Norton Scale is a risk screening tool to predict who will develop a pressure injury, not a staging tool for existing pressure injuries. If a pressure injury has already developed, use the NPUAP/EPUAP staging system (Stage 1–4, unstageable, deep tissue pressure injury) to characterize and track the wound. The Norton Score continues to inform care around an existing wound (higher risk means higher risk of additional wounds developing) but does not describe the severity of the existing injury.
Heels are the second most common site of pressure injuries (sacrum/coccyx is most common) and are particularly vulnerable in surgical and ICU patients with limited mobility. Standard pressure-redistributing mattresses are NOT sufficient for heel pressure injury prevention — heels must be specifically offloaded by elevating the entire lower leg with a pillow or foam wedge so the heels float free of the mattress. Commercial heel offloading boots are also effective. In any patient with Norton score below 14, document specifically that heels are offloaded in the bed — 'pressure-reducing mattress' alone without heel offloading is inadequate care.
Norton Scale originally described by Doreen Norton in 'An Investigation of Geriatric Nursing Problems in Hospital' (1962; reprinted Churchill Livingstone 1975). Validation studies: Goldstone & Goldstone (J Adv Nurs 1982); Perneger et al. (J Clin Epidemiol 1998). Meta-analyses: Pancorbo-Hidalgo et al. (J Adv Nurs 2006) — compared Norton, Braden, Waterlow; AUC 0.74–0.84 across tools. NICE Clinical Guideline 179 (2014, updated 2023) endorses Norton as a validated risk assessment tool for pressure ulcer prevention. Modified Norton Scale: Ek et al. (Scand J Caring Sci 1987).
Lower Norton totals indicate greater pressure injury risk and the need for intensified prevention planning.
Use in hospital, long-term care, and high-dependency settings to screen pressure injury risk at baseline and follow-up.
The Norton scale is a screening aid and has variable performance by population; it should complement, not replace, clinical skin and mobility assessment.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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