Assessment of risk for pressure ulcers with the Norton scale

Pressure ulcers are common among patients with reduced mobility, although in most cases they can be prevented if preventative measures are implemented in time. Standardized risk assessment instruments are often used to detect patients at high risk for pressure ulcers, one of which is the Norton scale.


What scientific studies are there on the use of the Norton Risk Assessment Tool to detect patients at high risk of pressure ulcers?

Table with identified studies

Table 1. Systematic reviews with low/medium risk of bias
Included studies Population/Intervention Outcome
Pancorbo-Hidalgo et al 2005 [1]
Total: 33 studies (6 assessed Norton)
3 Experimental studies assessing clinical effectiveness.
30 Clinical trials/Prospective cohort validation studies.
Risk assessment scales for pressure ulcer prevention.
82,77% Hospitals
10,34% Home care services, 6,89% Elder care centers.
Primary outcomes:
Pressure Ulcer incidence, instrument sensitivity and specifity.
Authors' conclusion:
“There is presently not enough evidence to claim that use of a risk assessment scales in clinical practice decreases pressure ulcer incidence. The use of a validated RAS, the Norton Scale, as a criterion for prevention intervention (pressure-reducing support surfaces) increases both its effectiveness and the application of a greater number of early prevention interventions. We found that the Braden and Norton Scales are better risk prediction tools than nurses’ clinical judgement.”
Park, Lee & Kwon 2016 [2]
Total: 29 studies (5 assessed Norton)
6 retrospective studies
23 prospective studies
The use of risk assessment scales for pressure ulcer prevention on the elderly. Primary outcomes: Sensitivity and specificity of the instruments.
Authors' conclusion:
“Results indicate that commonly used screening tools for pressure ulcer risk have limitations regarding validity and accuracy for use with older adults due to heterogeneity among studies.
“The development of more accurate assessment tools for the prediction of pressure ulcers is necessary to insure evidenced-based interventions are targeted where they can have the greatest impact”
García-Fernández, Pancorbo-Hidalgo & Agreda 2014 [3]
Total: 73 studies (16 assessed Norton)
57 different scales were used
Assessing the predictive capacity of both risk assessments scales and clinical judgment for pressure ulcers. Primary outcome: Predictive capacity (RR).
Authors' conclusion:
“The greatest predictive capacity was found for the Braden, Norton, EMINA, Waterlow, and Cubbin-Jackson scales. Based on our results, the pressure ulcer predictive capacity of the scales is significantly higher than that of the clinical judgment of nurses.”.


  1. Pancorbo-Hidalgo PL, Garcia-Fern, ez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: A systematic review. Journal of Advanced Nursing 2006;54:94-110.
  2. Park SH, Lee YS, Kwon YM. Predictive Validity of Pressure Ulcer Risk Assessment Tools for Elderly: A Meta-Analysis. Western journal of nursing research 2016;38:459-483.
  3. García-Fernández FP, Pancorbo-Hidalgo PL, Agreda JJ. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society / WOCN 2014;41:24-34.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Contact SBU:
Report no: ut201925
Registration no: SBU 2019/495