The 5 item Norton scale was the first pressure ulcer risk assessment that was developed and was intended for use with a geriatric hospital population (Norton et al. 1962).  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 and (5) incontinence.  They are measured on an ordinal scale from 1 to 4.

Number of items: N/a

Procedure/Administration: Raters indicate client status based on personal observation or chart review.  Scales are scored on a domain specific ordinal scale from 1 to 4.

How scored: 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.

Interpretability: 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 (Norton et al. 1962).

Acceptability: 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. 

Languages: N/a

Usability: The Norton scale is quick to administer and easy to score. There is no patient burden.

Time to administer: 5-10 minutes

Time to score: N/a

Training required: N/a

Availability: N/a

Equipment required: N/a

Summary: N/a

Psychometric Summary:









Predictive: Red light

Construct/SS: Yellow light



Note: TR= Test re-test; IC= Internal Consistency; Inter-O= Inter-observer; Intra-O= Intra-observer; SS= Sensitivity/Specificity.

Red light= A single study involving SCI subjects which has less than adequate findings of reliability, validity, and/or responsiveness.

Yellow light= A single study involving subjects with SCI which has adequate to excellent findings of reliability, validity, and/or responsiveness.

Green light= At least 2 studies involving subjects with SCI which have adequate to excellent findings of reliability, validity, and/or responsiveness.

N/a= No information.


  • 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.