Assessing pressure injuries with the Waterlow Score

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Pressure injuries (PI) continue to affect the lives of too many New Zealanders. Every year, an estimated 55,000 new PI occur, causing pain, disability, hospitalisation and sometimes even death. In addition to medical complications, PI can also have a significant financial impact on families and healthcare services.[1] Despite efforts to raise awareness and reduce PI in New Zealand, according to ACC PI claims increased by a massive 63% between 2009 and 2016.[2]

ACC, the Ministry of Health (MoH) and the Health Quality & Safety Commission are currently working together to implement a number of measures they hope will help reduce the number of PI. While these include some promising developments like the roll out of a national PI assessment and reporting programme, there is no mention yet of preventive programmes. Given that PI are largely avoidable and progressive, we wonder if more could be done to develop preventative measures.

How can we help reduce PI?

One of our Registered Occupational Therapist’s Sharon Woodward believes education is one of the most effective ways to prevent PI in the community. “Knowledge is power,” says Sharon. “Ensuring your client, their family and caregiver(s) understand the risks associated with PI is key. If everyone is aware of what to look for and what to do, then a PI can potentially be prevented in the early stages.”

Regular and consistent risk assessments

One of the best ways to help prevent PI 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 PI Prevention Score

There are several PI 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 PI. 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 (shown in the image below) 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 PI.

Click here for the downloadable version of the Waterlow Score. 

Sharon explains that the level of risk provided by the Waterlow Score can be used by OTs 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 PI risk and support a carer to move their client, check skin and prevent shear and skin damage during daily activities,” Sharon says.

Many OTs 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

Sharon says that in addition to good information and education, having access to the right equipment at the right time is critical for preventing PI. “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,” Sharon explains.

Seek specialist advice

There are more risk factors to consider for people with spinal injuries, or paediatric and bariatric individuals. Sharon recommends seeking advice from those with appropriate experience who can support your clinical reasoning; work with you to put in place an appropriate PI 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 PI.

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
PI are largely avoidable and preventing PI is not overly complicated. With robust policies, guidelines, action plans, regular auditing, staff training and knowledge, we believe most (if not all PI) 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