Waterlow Scale for Stratification of Pressure Sore Risk

 

Sex
		Female (2 points)
		Male (1 point)
Age
		14-49 years old (1 point)
		50-64 (2 points)
		65-74 (3 points)
		75-80 (4 points)
		81 + Years old (5 points)
Physical Build / Weight
		Average (0 points)
		Above average (1 point)
		Obese (2 points)
		Below average (3 points)
Continence
		Has catheter (0 points)
		Occasionally incontinent (1 point)
		Has catheter but incontinent of feces (2 points)
		Incontinent of urine and feces (3 points)
Abnormal Skin Condition
		Atrophic, tissue paper like (1 point)
		Dry (1 point)
		Edemetous (1 point)
		Clammy (1 point)
		discolored (2 points)
		Breakdown present (3 points)
Mobility
		full (0 points)
		Restless (1 point)
		Apathetic (2 points)
		Restricted (3 points)
		In traction (4 points)
		Chairbound (5 points)
Appetite
		average (0 points)
		Poor (1 point)
		NG tube / fluids only (2 points)
		Anorexic (3 points)
		Terminal Cachexia (8 points)
		Cardiac Failure (5 points)
		Peripheral Vascular Disease (5 points)
		Anemia (2 points)
		Smoker (1 point)
		Diabetic Neurologic Deficit (5 points)
		Multiple Sclerosis Neurologic Deficit (5 points)
		CVA Neurologic Deficit (5 points)
		Motor Sensory Neurologic Deficit (5 points)
		Paraplegic Neurologic Deficit (5 points)
		Recent Orthopedic Surgery Below Waist (5 points)
		Recent Spinal Anesthetic (over 2 hours table time) (5 points)
		On Cytotoxic Medications (4 points)
		On High Dose Corticosteroid (4 points)
		On Anti-inflamatory Medications (4 points)

 

Total Criteria Point Count:
 

 

Waterlow Score

 

10 to 14 points:	Patient at risk
15 to 19 points:	High risk
20 to 92 points:	Very high risk

 

 

References

1. Waterlow J. The history and use of the Waterlow card. Nurs Times. 1998 Feb 18-24;94(7):63-7. PubMed ID: 9536738
2. Wellard S, Lo K. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse. 2000 Jun;9(2):155-60. PubMed ID: 11855004