Norton Measure

Clinical Summary

Jump to: Tool Description | Interpretability | Measurement Property Summary

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.



  • Though each item comes with standardized descriptive criteria on the score sheet, descriptors for item scoring are very brief. 
  • A summary score ranging from 5 – 20 is calculated. 


MCID: not established
SEM: not established
MDC: not established

  • 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 is significantly (P<.01) and poorly correlated with the stage of the first pressure ulcer (Spearman’s r=-0.192) and the number of ulcers developed (Spearman’s r=-0.197).
  • 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. Janice Eng, Christie Chan

Date Last Updated:

 Feb 1, 2013