Clinical Assessment

Pressure Sore Assessment (Waterlow Scale)

A pressure ulcer risk assessment using the Waterlow Scale, the most widely used tool in UK care homes. The Waterlow Score helps identify residents at risk of pressure damage and guides the level of preventative intervention required. Scores ≥10 indicate risk; ≥15 indicate high risk; ≥20 indicate very high risk.

Care Handbook

0 — Average1 — Above Average / Obese2 — Below Average / Underweight

0 — Healthy1 — Tissue Paper / Dry1 — Oedematous2 — Clammy / Pyrexial3 — Discoloured3 — Broken / Grade 1+

1 — Male2 — Female1 — Age 14–492 — Age 50–643 — Age 65–744 — Age 75–805 — Age 81+

0 — Fully Mobile1 — Restless / Fidgety2 — Apathetic3 — Restricted4 — Bedbound / Inert5 — Chairbound

0 — Fully Continent1 — Occasionally Incontinent / Catheter2 — Catheter / Incontinent of Faeces3 — Double Incontinence

0 — Adequate1 — Poor / Nasogastric / IV2 — Critical / NPO

0 — None4 — Diabetes / MS / CVA / Paraplegia4 — Peripheral Neuropathy

0 — None2 — Orthopaedic / Spinal2 — On Table > 2 Hours3 — On Table > 6 Hours

0 — None4 — Cyto-toxics / Long-Term Steroids / Anti-Inflammatories

<10 — Not at Risk10–14 — At Risk15–19 — High Risk20+ — Very High Risk

Every 2 HoursEvery 3 HoursEvery 4 HoursAs Required