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The Waterlow Score is a comprehensive pressure ulcer risk assessment tool developed by Judy Waterlow in 1985, widely used particularly in the United Kingdom and Commonwealth healthcare systems. It is considered one of the three major pressure ulcer risk assessment scales alongside the Braden and Norton scales, and is distinguished by its broader range of risk factors including special considerations for surgical patients.
The Waterlow Score evaluates seven categories of risk factors: build/weight for height, skin type and visual risk areas, sex and age, continence, mobility, appetite/nutrition, and special risks (including tissue malnutrition, neurological deficit, and major surgery/trauma). This comprehensive approach makes it particularly valuable in surgical and acute care settings where patients may have multiple interacting risk factors.
Unlike some simpler tools, the Waterlow Score explicitly includes surgical and medication-related risk factors. Patients undergoing major surgery (especially operations lasting more than 2 hours), those on cytotoxic drugs, high-dose anti-inflammatory steroids, or those with conditions affecting tissue perfusion receive additional risk points. This makes the Waterlow Score particularly relevant in perioperative care.
Scores are categorized as: not at risk (below 10), at risk (10-14), high risk (15-19), and very high risk (20 or above). Each category triggers specific levels of preventive intervention. The higher the score, the more intensive the prevention protocol should be, including more frequent repositioning, specialized support surfaces, nutritional supplements, and closer monitoring.
The Waterlow Score's inclusion of body mass index at both extremes (underweight and obese) reflects the clinical reality that both malnutrition and obesity increase pressure ulcer risk, though through different mechanisms. Underweight patients have less subcutaneous tissue to protect bony prominences, while obese patients have increased pressure on tissues and may be more difficult to reposition effectively.
Research on the Waterlow Score has shown it tends to have high sensitivity but lower specificity compared to the Braden Scale, meaning it identifies most at-risk patients but may also over-predict risk in some patients. This characteristic is generally considered acceptable in clinical practice, as the consequences of missing an at-risk patient (developing a pressure ulcer) are more serious than the consequences of over-prevention (additional repositioning and skin care).
The Waterlow Score sums points from seven categories (higher = more risk):
Risk Category: 0=Not at risk (<10), 1=At risk (10-14), 2=High risk (15-19), 3=Very high risk (20+).
A Waterlow score below 10 indicates no significant pressure ulcer risk. 10-14 indicates at risk — implement basic prevention measures (regular repositioning, skin inspection, moisture management). 15-19 indicates high risk — use pressure-relieving devices, increase repositioning frequency, optimize nutrition. 20 or above indicates very high risk — maximum prevention protocol with specialty surfaces, nutritional support, and intensive monitoring. Care Level matches Risk Category.
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Waterlow 3: Not at risk. Average build, healthy skin, mobile, continent. Standard care sufficient.
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Waterlow 26: Very high risk. Underweight 82-year-old, edematous skin, bed-bound after major surgery. Maximum prevention protocol.
The Waterlow Score is a comprehensive pressure ulcer risk assessment tool evaluating seven categories of risk factors. Developed in 1985, it is widely used in UK healthcare. Higher scores indicate higher risk.
Waterlow tends to have higher sensitivity (catches more at-risk patients) but lower specificity (more false positives) than Braden. Waterlow includes surgical and medication risk factors not in Braden.
A score of 15-19 indicates high risk, and 20 or above indicates very high risk. Scores of 10-14 indicate the patient is at risk for pressure ulcers.
Surgery involves prolonged immobility on the operating table, reduced blood pressure under anesthesia (reducing tissue perfusion), and potential hypothermia — all of which increase pressure ulcer risk.
Obesity increases pressure on tissues at bony prominences, makes repositioning more difficult, creates skin folds where moisture accumulates, and may be associated with diabetes and reduced circulation.
Underweight patients have less subcutaneous tissue to cushion bony prominences, are more likely to be malnourished (impairing skin integrity and healing), and may have reduced immune function.
On admission and whenever clinical condition changes. In acute care, daily to twice-weekly reassessment is typical. After surgery, immediate reassessment is recommended.
Special risks include tissue malnutrition conditions (terminal cachexia, cardiac failure, peripheral vascular disease, anemia, smoking), neurological deficits (diabetes, MS, CVA, paraplegia), and surgical/trauma factors (duration of surgery, medications).
Yes, the Waterlow Score can be used in community and home care settings. It is particularly useful for patients being discharged from hospital to ensure appropriate prevention measures continue at home.
The Waterlow Score was developed based on clinical experience and literature review. While it has been widely used for decades, some critics note that its psychometric properties have been less rigorously studied than those of the Braden Scale.
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