What are the Braden and Norton Scales?
Pressure ulcers, also known as bedsores or pressure injuries, are localized injuries to the skin and underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear. The Braden and Norton scales are standardized, evidence-based tools designed to help clinicians objectively predict which patients are most susceptible to developing these injuries.
The Braden Scale: A Deeper Look
Developed in 1987 by nurses Barbara Braden and Nancy Bergstrom, the Braden Scale is a widely used and respected tool in healthcare settings, particularly in the United States. It is considered a more comprehensive tool than the older Norton scale, assessing six key areas related to pressure ulcer risk. The scale uses a total score ranging from 6 to 23, where a lower score indicates a higher risk of skin breakdown.
The six subscales of the Braden assessment include:
- Sensory Perception: This measures a patient's ability to respond meaningfully to pressure-related discomfort. Scoring ranges from 1 (Completely Limited) to 4 (No Impairment), assessing consciousness and neurological function.
- Moisture: Evaluates the degree to which a patient's skin is exposed to moisture, which can lead to skin maceration and breakdown. Scoring is from 1 (Constantly Moist) to 4 (Rarely Moist).
- Activity: Measures the level of physical activity. A patient who is bedfast (score 1) is at higher risk than one who walks frequently (score 4).
- Mobility: This is the ability to change and control body position. The score ranges from 1 (Completely Immobile) to 4 (No Limitations).
- Nutrition: Assesses the patient's usual food intake pattern, as poor nutrition can compromise skin integrity. Scores range from 1 (Very Poor) to 4 (Excellent).
- Friction and Shear: This is unique to the Braden scale and assesses the potential for a patient's skin to rub or slide against surfaces. This category is scored differently, from 1 (Problem) to 3 (No Apparent Problem).
The Norton Scale: The Foundation of Risk Assessment
Introduced in the 1960s by Nurse Doreen Norton, this scale was one of the first standardized risk assessment tools developed to predict pressure ulcer risk. While simpler than the Braden scale, it remains a valuable tool, especially for quick assessments in less complex patient scenarios. The Norton scale assesses five key factors, each scored from 1 (worst) to 4 (best), resulting in a total score from 5 to 20.
The five components of the Norton assessment are:
- Physical Condition: General physical health, scored from Good to Very Bad.
- Mental Condition: Cognitive awareness, scored from Alert to Stuporous.
- Activity: The level of a patient's mobility, from Ambulant to Bedfast.
- Mobility: The capacity to change position, from Full to Immobile.
- Incontinence: The degree of moisture exposure due to incontinence, from Not Incontinent to Doubly Incontinent (urinary and fecal).
Comparison: Braden vs. Norton Scale
| Feature | Braden Scale | Norton Scale |
|---|---|---|
| Year Developed | 1987 | 1962 |
| Number of Subscales | 6 | 5 |
| Subscale Categories | Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear | Physical Condition, Mental Condition, Activity, Mobility, Incontinence |
| Scoring Range | 6–23 (Lower score = Higher risk) | 5–20 (Lower score = Higher risk) |
| Risk Threshold | ≤18 or lower indicates at-risk status | ≤14 indicates high risk |
| Key Differentiation | Includes Nutrition and Friction/Shear subscales, offering more detail. |
Simpler and faster to administer. |
| Best Use Case | Widely applicable across various settings, especially for complex or high-risk patients. | Quick assessments, especially for elderly or less complex patients. |
Interpreting Scores and Guiding Care
The most important aspect of using these scales is the action taken based on the results. A risk score is not a diagnosis but a guide for intervention. Regardless of which scale is used, a higher-risk score necessitates a proactive care plan. This might include implementing pressure-relieving devices, turning schedules, managing moisture, and ensuring adequate nutrition. The specific thresholds for risk categories vary slightly depending on the scale and clinical setting, but the core principle remains consistent: early identification is key to effective prevention.
Evidence suggests the Braden scale, due to its inclusion of more factors, may be more predictive in diverse patient populations, such as those in intensive care units. However, the Norton scale is still effective and sufficient for many patient groups, particularly older adults. What is most critical is the consistent use of a validated tool in conjunction with thorough clinical judgment to formulate a comprehensive care plan.
Conclusion
The Braden and Norton scales have long served as fundamental tools for pressure ulcer risk assessment in clinical practice. By providing a structured, objective framework, they help healthcare providers identify at-risk patients and prioritize preventive measures. While the Braden scale offers a more detailed assessment by including nutrition and friction/shear, the Norton scale remains a straightforward and effective option. The ultimate goal is to leverage these assessments to implement timely and targeted interventions, improving patient outcomes and ensuring skin health across various care environments. For further reading on pressure ulcer prevention, visit the Agency for Healthcare Research and Quality.
