Estimates a patient’s risk of developing pressure ulcers using the Waterlow risk assessment.
INSTRUCTIONS
Complete each assessment domain using the patient’s current clinical status. The total Waterlow Score is calculated automatically and interpreted according to the published risk thresholds.
Sex*
Age group*
14–49 years+1
50–64 years+2
65–74 years+3
75–80 years+4
81 years or older+5
Build or weight for height*
BMI 20–24.90
BMI 25–29.9+1
BMI 30 or greater+2
BMI below 20+3
Skin condition or visible risk area*
Healthy skin0
Thin or tissue-paper skin+1
Dry skin+1
Oedematous skin+1
Clammy skin or pyrexia+1
Discoloured skin, grade 1+2
Broken skin or pressure injury, grades 2–4+3
Mobility*
Fully mobile0
Restless or fidgety+1
Apathetic+2
Restricted mobility+3
Bedbound, including traction+4
Chairbound, including wheelchair use+5
Continence*
Complete continence or catheterised0
Urinary incontinence+1
Faecal incontinence+2
Urinary and faecal incontinence+3
Recent weight loss*
No recent weight loss0
Unsure+2
0.5–5 kg+1
More than 5–10 kg+2
More than 10–15 kg+3
More than 15 kg+4
Eating poorly or reduced appetite*
Tissue malnutrition or associated risk*
None identified0
Smoking+1
Anaemia, haemoglobin below 8 g/dL+2
Single-organ failure: respiratory, renal, or cardiac+5
Peripheral vascular disease+5
Terminal cachexia+8
Multiple-organ failure+8
Neurological deficit*
None0
Moderate+4
Moderate to severe+5
Severe+6
Major surgery or trauma*
None0
Orthopaedic or spinal surgery+5
Procedure lasting more than 2 hours+5
Procedure lasting more than 6 hours+5
High-dose steroids, cytotoxic medicines, or anti-inflammatory medicines*
