Waterlow pressure sore prevention score

(c) J Waterlow 1985, revised 2005. See http://www.judy-waterlow.co.uk for information on the Waterlow score, it’s use, and copyright.
This version does not use the Malnutrition Screening Tool.

status:draft
version:0.1
source:NHS Fife
tags: tissue viability, pressure care

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average - 0
above average - 1
obese - 2
below average - 3
 
competely/catheterised - 0
urinary incontinence - 1
incontinent of faeces - 2
urinary and faecal incontinence - 3
 
 
fully - 0
restless/fidgety - 1
apathetic - 3
restricted - 3
bedbound - 4
chairbound - 5
 
male - 1
female - 2
 
14-49 - 1
50-64 - 2
65-74 - 3
75-80 - 4
81+ - 5
 
average - 0
poor - 1
NG tube/fluids only - 2
NBM/anorexic - 3
Special risks (repeat: *)
 
tissue malnutrition - 8
cardiac failure - 5
peripheral vascular disease - 5
anaemia - 2
smoking - 1
 
diabetes 4-6
motor/sensory 4-6
MS 4-6
paraplegia 4-6
CVA 4-6
 
orthpaedic (below waist, spinal) - 5
on table > 2hrs - 5
on table > 6hrs - 8
 
steroids, cytotoxics, high dose anti-Inflam - 4
 
10+ - at risk
15+ - high risk
20+ - very high risk


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