Comparison of SA Skin Assessment to Norton and Braden Scales

SA Skin Assessment	Norton	Modified Norton	Braden
1 - 5 - Normal Risk 6 - 10 - Moderate Risk 11 - 15 - High Risk 16 - 20 - Very High Risk	Scores of 14 or less rate the patient as 'at risk' Maximum score=20 Minimum Score=5	Scores of 14 or less rate the patient as 'at risk' 24-25=low risk 19-23=medium risk 14-18=high 9-13=very high	Scores of 16 or less are considered to be at risk of developing pressure ulcers. 15 or 16 = low risk 13 or 14 = moderate risk 12 or less = high risk
Perception Cog Skill=0,1,2,3 Comatose=1	Mental Condition: Alert=4 Apathetic=3 Confused=2 Stupor=1	Mental Condition: Alert=4 Apathetic=3 Confused=2 Stupor=1	Impairment; Ability to respond to related discomfort None=4 Slightly impaired=3 Very limited=2 Completely limited=1
Diagnosis DVT=3 PVD=3 Diabetes=3	Physical Condition: Good=4 Fair=3 Poor=2 Very bad=1	Physical Condition: Good=4 Fair=3 Poor=2 Very bad=1 Additional Diseases: None=4 Undermine of resistance, fever, diabetes=3 Multiple sclerosis, adiposis=2 Artery occlusion=1
Locomotion Locomotion on unit = 0,1,2,3 or 4	Activity: Ambulant=4 Walk w/ help=3 Chair-bound=2 Bed=1	Activity: Ambulant=4 Walk w/ help=3 Chair-bound=2 Bed=1	Activity: Bedfast=1 Chair-fast=2 Walks occasionally=3 Walks frequently=4
Mobility Bed Mobility = 0,1,2,3 or 4	Mobility: Full=4 Slightly limited=3 Very limited=2 Immobile=1	Mobility: Full=4 Slightly limited=3 Very limited=2 Immobile=1	Mobility : Completely immobile=1 Very limited=2 Slightly limited=3 No limitations=4 Friction & Shear: Problem=1 Potential problem=2 No apparent problem=3
Current ulcers Worst stasis ulcer=0,1,2,3 or 4 Worst pressure ulcer=0,1,2,3 or 4	Not considered	Not considered	Not considered
Previous history of ulcers Ulcer healed in last 90 days=1	Not considered	Not considered	Not considered
Incontinence Bowel=0,1,2,3 or 4 Bladder=0,1,2,3 o4 4	Continence: Not=4 Occasional=3 Usually urine=2 Doubly=1	Continence: Not=4 Occasional=3 Usually urine=2 Doubly=1	Degree to which skin is exposed to moisture: Constantly moist=1 Moist: Skin is often but not always moist=2 Occasionally moist=3 Rarely moist=4
Hydration Edema=3 Dehydration=3	May be part of physical condition, see above	May be part of physical condition, see above
Nutrition: Intake less than body requirements=1	May be part of physical condition, see above	May be part of physical condition, see above	Nutrition: Very poor=1 Probably inadequate=2 Adequate=3 Excellent=4
Other skin problems Abrasions/Bruises=1 Rash=1 Open lesions=1 Burns=1 Cuts, Tears=1 Surgical wounds=1 Open lesions of feet=1 Other foot problems=1		Condition of Skin: OK=4 Scaly, dry=3 Moist=2 Wounds, allergic lacerations=1
		Readiness for co-operation/motivation: Full=4 Less=3 Partly=2 None=1
		Age: <10=4 <30=3 <60=2 >60=1

Value provided by SAEnCompass as the total points for the following. These values should only be used in conjunction with the assessor's professional judgment, not as arbitrary numbers.

1 - 5 - Normal Risk

6 - 10 - Moderate Risk

11 - 15 - High Risk

16 - 20 - Very High Risk

Bladder and Bowel Continence Coding:

0. Continent - Complete control (including control achieved by care that

involves prompted voiding, habit training, reminders, etc.).

1. Usually Continent - Bladder, incontinent episodes occur once a week or

less; Bowel incontinent episodes occur less than once a week.

2. Occasionally Incontinent - Bladder incontinent episodes occur two or more

times a week but not daily; Bowel incontinent episodes occur once a week.

3. Frequently Incontinent - Bladder incontinent episodes tend to occur daily,

but some control is present (e.g., on day shift); Bowel incontinent episodes

occur two to three times per week.

4. Incontinent - Has inadequate control. Bladder incontinent episodes occur

multiple times daily; Bowel incontinent is all (or almost all) of the time.

Choose one response to code level of bladder continence and one response to

code level of bowel continence for the resident over the last 14 days.

Code for the resident’s actual bladder and bowel continence pattern - i.e., the

frequency with which the resident is wet and dry during the 14-Day assessment

period. Do not record the level of control that the resident might have achieved

under optimal circumstances.

For bladder incontinence, the difference between a code of “3” (Frequently

Incontinent) and “4” (Incontinent) is determined by the presence (“3”) or absence

(“4”) of any bladder control.

Norton Interpretation: Maximum score 20; Minimum score 5; At risk for pressure ulcer if score <= 14

Mobility Ability to change and control body position	1. Completely immobile: Does not make even slight changes in body or extremity position without assistance.	2. Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.	3. Slightly limited: Makes frequent though slight changes in body or extremity position independently.	4. No limitations: Makes major and frequent changes in position without assistance.
Nutrition Usual food intake pattern	1. Very poor: Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR is NPO[1] and/or maintained on clear liquids or IV[2] for more than 5 days.	2. Probably inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR receives less than optimum amount of liquid diet or tube feeding.	3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, OR is on a tube feeding or TPN[3] regimen, which probably meets most of nutritional needs.	4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Friction and shear	1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.	2. Potential problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.	3. No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.