Norton scale
The Norton scale is a tool for assessing the risk of bedsores in nursing and elderly care .
The nurse Doreen Norton developed the scale in 1962, and in 1980 it was translated into German. The original scale measured the five influencing factors “physical condition”, “mental condition”, “activity”, “mobility” and “incontinence”. Each of these factors is rated on a four-point scale, from low (four points) to high risk (one point). There was a risk of bedsores if the sum of the points was 14 or less. At the beginning of the 1970s, Davina J. Gosnell conducted a study to identify pressure ulcer risk factors using an adapted Norton scale, which later became known as the Gosnell scale .
In 1985, nursing scientist Christel Bienstein expanded the Norton scale to include the four factors “willingness to cooperate / motivation”, “age of the patient”, “skin condition” and “additional diseases”, and set the limit at 25.
The current number of points should be checked and documented about twice a week and if the patient's condition changes, and new measures initiated if necessary.
With a score of over 25, there is only a low risk of pressure ulcers and no further prophylactic measures are required. If the patient achieves a score between 20 and 25, the risk is medium and repositioning and soft positioning is required. In patients with a medium to high risk (15–19 points), repositioning should be carried out regularly for two hours. A special bed or a pressure ulcer mattress is recommended with a score of 14 points or less.
In addition to the Norton scale, the risk of bedsores can also be determined with the Braden scale , the Waterlow scale or the Medley scale .
The extended Norton scale
| Points | 4 points | 3 points | 2 points | 1 point |
|---|---|---|---|---|
| Willingness to cooperate / motivate | full | little | partially | no |
| Age | <10 | <30 | <60 | > 60 |
| Skin condition | okay | scaly, dry | wet | Wounds, allergies, cracks |
| Additional illnesses | no |
Deficiency of the immune system , fever, diabetes mellitus , anemia |
MS , obesity , cachexia , cancer |
Arterial Disease |
| Physical state | Well | passable | bad | very bad |
| Mental state | clear | apathetic, listless | confused | stuporous |
| activity | goes without help | goes with help | wheelchair needs | bedridden |
| agility | full | hardly restricted | very limited | fully restricted |
| Incontinence | no | sometimes | mostly urine ( urinary incontinence ) | Urine and stool ( fecal incontinence ) |
literature
- Liliane Juchli : Care. Practice and theory of health and nursing care. 8., revised. Edition. Thieme-Verlag, Stuttgart 1997, ISBN 3-13-500028-1 .
Individual evidence
- ^ Nicole Menche, Tilmann Klare (ed.): Care concrete. Internal Medicine. 3. Edition. Urban & Fischer, Munich / Jena 2001.
- ↑ C. Bienstein, G. Schröder, M. Braun, K. Neander: Decubitus. Challenge for carers. Thieme, Stuttgart 1997, ISBN 3-13-101951-4 .