Assessing pressure injuries with the Waterlow Score

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Pressure injuries continue to affect the lives of too many New Zealanders. Every year, an estimated 55,000 new pressure injuries occur, causing pain, disability, hospitalisation and sometimes even death. In addition to medical complications, pressure injuries can also have a significant financial impact on families and healthcare services. Despite efforts to raise awareness and reduce pressure injuries in New Zealand, according to ACC pressure injuries claims increased by a massive 63% between 2009 and 2016.

How can we help to reduce a pressure injury?

Education is one of the most effective ways to prevent pressure injuries in the community. Knowledge is definitely power and ensuring your client, their family and caregiver(s) understand the risks associated with pressure injuries is key. If everyone is aware of what to look for and what to do, then a pressure injury can potentially be prevented in the early stages.

Regular and consistent risk assessments

One of the best ways to help prevent pressure injuries is to carry out timely, regular and structured assessments of vulnerable skin areas, to determine an individual’s level of risk. The National Pressure Ulcer Advisory Panel guidelines encourage carers and clinicians to use a standardised assessment tool, along with their clinical judgement. While the choice of tool is up to you, it’s important that everyone involved in a person’s care is on the same page. If healthcare professionals use the same assessment tool, that can transfer between the home, hospital or care facilities, then a client is more likely to receive seamless care.

The Waterlow Pressure Injury Prevention Score

There are several pressure injuries assessment tools in use including the Norton Scale and Braden Scale, however the most commonly used and easily understood is the Waterlow Score.

The Waterlow Score is an interdisciplinary assessment that determines an individual’s risk of developing a pressure injuries. The scale is a baseline assessment of a client’s condition that covers a wide variety of factors including mobility, continence, malnutrition and special risks. One side of the scorecard illustrates the risk assessment scoring system, while the other provides guidance on nursing care, types of preventative aids associated with each level of risk, wound assessment and dressings. The Waterlow Score will lead to a plan of action to prevent the development of a pressure injuries.

Click here for the downloadable version of the Waterlow Score

The level of risk provided by the Waterlow Score can be used by Occupational Therapists to form part of the rationale for selecting appropriate support surfaces (seating, mattress etc.) and other equipment. It can be really helpful for selecting what equipment is needed to reduce the pressure injuries risk and support a carer to move their client, check skin and prevent shear and skin damage during daily activities.

Many Occupational Therapists understand that the Waterlow Score is not a one-off assessment and clinicians should reassess individuals regularly, especially if there is a change in condition or environment.

Right equipment at the right time

In addition to good information and education, having access to the right equipment at the right time is critical for preventing pressure. Waiting too long for equipment to relieve pressure areas often makes everything worse, resulting in longer recovery times and potentially hospital intervention if the skin opens and infection sets in.

Seek specialist advice

There are more risk factors to consider for people with spinal injuries, or paediatric and bariatric individuals. We recommend seeking advice from those with appropriate experience who can support your clinical reasoning; work with you to put in place an appropriate pressure injury management plan and help find the right equipment.

Ongoing care

Once your client has been assessed, simple tools like the SSKIN approach can help manage and prevent pressure injury.

Surface – supportive and pressure relieving surface 

Skin inspection – at regular intervals to find any potential areas of damage

Keep Moving – encouraging clients to change position regularly

Incontinence – keeping clients clean and dry to protect their skin

Nutrition – healthy eating with plenty of fluids to nourish the skin

Pressure injuries are largely avoidable and preventing a pressure injury is not overly complicated. With robust policies, guidelines, action plans, regular auditing, staff training and knowledge, we believe most (if not all pressure injuries) could be prevented.


[1] KPMG. The Case for Investment in a Quality Improvement Programme to Reduce Pressure Injuries in New Zealand, 2016

[2] ACC. Guiding Principles for Pressure Injury Prevention and Management in New Zealand, 2017