WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICY
RING SCORES IN TABLE, ADD TOTAL. MORE THAN 1 SCORE/CATEGORY CAN BE USED
BUILD/WEIGHT ¨ SKIN TYPE ¨ SEX ¨ NUTRITION
FOR HEIGHT VISUAL RISK AREAS AGE
AVERAGE 0 HEALTHY 0 MALE 1 A - HAS PATIENT LOST B - WEIGHT LOSS SCORE
BMI (20 – 24.9) TISSUE PAPER 1 FEMALE 2 WEIGHT RECENTLY 0.5 – 5kg - 1
ABOVE AVERAGE 1 DRY 1 14 - 49 1 YES – GO TO B 5 - 10kg - 2
BMI (25 – 29.9) OEDEMATOUS 1 50 - 64 2 NO – GO TO C 10 – 15kg - 3
OBESE 2 CLAMMY, PYREXIA 1 65 – 74 3 UNSURE – GO TO C > 15kg - 4
BMI > 30 DISCOLOURED 2 75 – 80 4 & SCORE 2 UNSURE - 2
BELOW AVERAGE 3 STAGE 1 81 + 5
BMI > 20 PRESSURE ULCER C – PATIENT EATING POORLY/LACK OF APPETITE
BMI = WT(Kg)/ HT (m2) STAGE 2 – 4 3 NO – SCORE 0 YES - SCORE 1
CONTINENCE ¨ MOBILITY ¨ SPECIAL RISKS
COMPLETE/ 0 FULLY 0 TISSUE MALNUTRITION ¨ NEUROLOGICAL DEFICIT ¨
CATHETERISED RESTLESS/FIDGETY 1
URINE INCONT. 1 APATHETIC 2 TERMINAL CACHEXIA 8 DIABETES, MS, CVA 4 - 6
FAECAL INCONT. 2 RESTRICTED 3 MULTIPLE ORGAN FAILURE 8 MOTOR SENSORY
URINARY + FAECAL 3 BEDBOUND 4 SINGLE ORGAN FAILURE 5 PARAPLEGIA (MAX OF 6)
INCONTINENCE E.G. TRACTION (RESP, RENAL, CARDIAC, )
CHAIRBOUND 5 PERIPHERAL VASCULAR 5 MAJOR SURGERY OR TRAUMA
E.G. WHEELCHAIR DISEASE
ANAEMIA (Hb < 8) 2 ORTHPAEDIC/SPINAL 5
SMOKING 1 ON TABLE > 2 HR* 5
ON TABLE > 6 HR* 8
MEDICATION
CYTOTOXICS, STEROIDS, ANTI-INFLAMMATORY MAX OF 4
38. The Uses of the Waterlow Card
a. To provide a quick, simple and comprehensive method of assessing the risk of a patient developing a pressure ulcer.
b. To place patients in one of three bands of increasing risk to enable appropriate cost effective preventative aids and nursing resources to be allocated.
c. To provide objective evidence of risk so that patients can be placed into a priority order for the allocation of resources.
d. To provide objective evidence of need to management, should extra resources be needed.
Note: Nurses by virtue of their ‘accountablility’ to their patients? , must be prepared to present sound financial formal proposals to management based on objective evidence if there is a need. If management does not respond, then the nurses ‘accountablility’ should be, again formally, passed on to the person in the management structure who refuses the request, and documented in the patient’s notes.
e. To ensure by periodic reassessment, that equipment, such as the more expensive automated bed systems, is reallocated when a patient starts to recover, and their risk category reduces.
The frequency of reassessment depends on the area of care. In acute areas of care for example, reassessment could be needed daily. In long stay residential care or Community, monthly reassessments would be adequate, unless the patients condition had changed due to a cold, change in medication etc.
f. To form the cornerstone of a Hospital Pressure Ulcer Prevention Policy, which must include Assessment and Reassessment, as no Policy will be effective unless patients are effectively screened for risk on admission and for the duration of their stay. The advantages of a Policy cannot be too highly stressed. It is the document, subject to audit and review, which can add flesh to bare bones of scoring system, from evidence collected within the hospital. It can give guidance on:
i. The appropriate risk thresholds to be applied in various areas.
ii. The timing of reassessments.
iii. The value of preventative aids and nursing regimes in reducing risk. The word ‘guidance’ is used deliberately. As no one patient is identical to another, it is still the responsibility of the assessing nurse to consider all the factors when making a professional judgement on what course of action to take. The decisions and reasons for those decisions must be documented.
g. To provide objective evidence that the appropriate measures were taken, should the questions of litigation arise.
COMMUNITY, NURSING & RESIDENTIAL HOME USE
When the Waterlow card is being used in the Community or in the Nursing and Residential homes it is vital to recognise that this environment is markedly different from the one in which the scoring system was developed. The risk factors are still the same, but can be alleviated by the client having:
i. A good quality mattress, duvet for his/her bed.
ii. A good quality armchair to sit out in.
iii. A caring relative or friend who keeps a constant eye on them and provides good nutritious meals, for example.
These factors raise the risk threshold so that if a person is discharged from Hospital with a stated ‘Waterlow score’ this score must be reviewed in the light of the changed circumstances to determine the requirements of the clients. By working in this manner and using the same assessment system in all areas of care, the patient can receive ‘seamless care’ as they move to and fro between Hospital, nursing/residential homes, or their own home.
Detailed comparison of the revised Waterlow Risk Assessment Scoring System with the original.
1. Build/Weight for height – BMI scores added
2. Continence – specific references to urinary and faecal incontinence used instead of ‘doubly incontinent’
3. Skin Type, Visual Risk Areas – definitions of ‘Discoloured’ and Broken/Spot given in terms of ulcer classification grade.
4. Mobility – extended definitions of Bedbound and Chairbound e.g ‘traction’ and ‘wheelchair bound’
5. Sex, Age – No change
6. Appetite – This has been replaced by ‘Nutritional Status’, to enhance the importance of nutrition. The score has been calculated by using a Malnutrition Screening Tool (MST)
7. Tissue Malnutrition – 2 definitions have been added to take account of single and multiple organ failure. Anaemia is now identified by Hb < 8.
8. Neurological Deficit – Limits the score for this parameter to 6.
9. Major Surgery/Trauma – Extends items to include a period of over 6 hours on the operating table. Warning is given that, provided that recovery is straightforward, this score can be discounted after 48 hours. Due to advances in surgical techniques and anaesthetics ‘on table >6 hours’ has been added.
Medication – A maximum of 4 is allowed for this parameter.