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Waterlow Pressure Sore Risk Scale

Purpose: To use the Waterlow Pressure Sore Risk Score to assess a patient's risk for developing a pressure sore.

Description

The Waterlow Pressure Sore Risk Scale can be used to assess a patient for the risk of developing a pressure sore. This can be used to help guide treatment and preventive measures.


Parameters:

(1) age

(2) sex

(3) body build

(4)appetite

(5) continence of urine and feces

(6) mobility

(7) skin appearance in risk areas

(8) special risks

(8a) disorders associated with tissue malnutrition

(8b) neurological deficits

(8c) medication

(8d) recent surgery or trauma

 

Parameter

Finding

Points

sex

female

2

 

male

1

age

14 - 49

1

 

50 - 64

2

 

65 - 74

3

 

75 - 80

4

 

>= 81

5

build, weight for height

average

0

 

above average

1

 

obese

2

 

below average

3

appetite

average

0

 

poor

1

 

nasogastric (NG) tube

2

 

fluids only

2

 

nothing by mouth, anorexic

3

continence

complete (urine and stool)

0

 

catheterized and continent feces

0

 

occasionally incontinent

1

 

catheterized and incontinent feces

2

 

doubly incontinent

3

mobility

fully

0

 

restless or fidgety

1

 

apathetic

2

 

restricted

3

 

inert or in traction

4

 

chair-bound

5

skin type, visual appearance in risk areas

healthy

0

 

tissue paper

1

 

dry

1

 

edematous

1

 

clammy

1

 

discolored

2

 

broken spot

3

 

where:

• NG tube and fluids only are one entry in the original table

• complete continence and catheterized with fecal continence are one entry in the original table

 

Special Risk Factors

Findings

Points

terminal cachexia

 

8

cardiac failure

 

5

peripheral vascular disease

 

5

anemia

 

2

smoking

 

1

neurological deficit

moderate

4

 

moderate-to-severe

5

 

severe

6

major surgery or trauma

orthopedic, below waist or spinal

5

 

on table > 2 hours

5

medication

steroids, cytotoxic agents, high dose anti-inflammatory agents

4

 

where:

• The original table had a category Tissue Malnutrition which included terminal cachexia, cardiac failure, peripheral vascular disease, anemia and smoking. This was restructured since the instructions implied that each could be scored, rather than one score being given for the category.

• Neurological deficits includes strokes, diabetes mellitus, multiple sclerosis, paraplegia and motor/sensory loss.

 

score =

= SUM(points for parameters) + SUM(points for special risk factors)

 

Interpretation:

• minimum score: 0

• maximum: > 45

 

Score

Risk

< 10

low risk

10 - 14

at risk

15 - 19

high risk

>= 20

very high risk

 


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Specialty

Objective

ICD-10