Affix Patient Label here or record WATERLOW RISK

NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ASSESSMENT SCORE
NHS NO:
HOSP NO:
This form to be completed within 4 hours of admission. A Clinical Incident
form must be completed on all patients with pressure ulcers. It must be repeated
D.O.B: D D M M Y Y Y Y MALE FEMALE if the pressure ulcer deteriorates. An RCA must also be completed on all patients
with hospital-acquired category 3 & 4 pressure ulcers. For catagory 3 & 4 pressure
WARD_____________________ CONS_______________________ ulcers the Adult Protection Team must be informed within 24 hours.

RISK CATEGORY AND SCORE Date

10+ at risk 15+ high risk 20+ very high risk Time
Build/Weight for Height Average BMI = 20 - 24.9 0 0 0 0 0
Above Average BMI = 25 - 29.9 1 1 1 1 1
Obese BMI = > 30 2 2 2 2 2
Below Average BMI = <20 3 3 3 3 3
Continence Complete/Catheterised 0 0 0 0 0
Urinary Incontinence 1 1 1 1 1
Faecally Incontinence 2 2 2 2 2
Urinary & Faecal Incontinence 3 3 3 3 3
Skin Type/Visual Risk Areas Healthy 0 0 0 0 0
Tissue Paper 1 1 1 1 1
Dry 1 1 1 1 1
Oedematous 1 1 1 1 1
Clammy / Pyrexia 1 1 1 1 1
Discoloured - Grade 1 2 2 2 2 2
Broken/Spots - Grade 2- 4 3 3 3 3 3
Mobility Fully 0 0 0 0 0
Restless/Fidgety 1 1 1 1 1
Apathetic 2 2 2 2 2
Restricted 3 3 3 3 3
Bed bound inert/traction 4 4 4 4 4
Chair Bound eg Wheelchair 5 5 5 5 5
Sex/Age Male 1 1 1 1 1
Female 2 2 2 2 2
14 - 49 1 1 1 1 1
50 - 64 2 2 2 2 2
65 - 74 3 3 3 3 3
75 - 80 4 4 4 4 4
81 + 5 5 5 5 5
Appetite Average 0 0 0 0 0
Poor 1 1 1 1 1
NG Tube/Fluids Only 2 2 2 2 2
NBM/Anorexic 3 3 3 3 3
Special Risks
Tissue Malnutrition Terminal Cachexia 8 8 8 8 8
Cardiac failure 5 5 5 5 5
Peripheral vascular disease 5 5 5 5 5
Anaemia (Hb <8) 2 2 2 2 2
Smoking 1 1 1 1 1
Neurological Deficit Diabetes, MS, CVA, renal failure 4-6 4-6 4-6 4-6 4-6
motor/sensory, paraplegia
Major Surgery/Trauma or Orthopaedic/Spinal* 5 5 5 5 5
Organ failure On Table > 2 Hours* 5 5 5 5 5
On Table > 6 Hours* 8 8 8 8 8
Single organ failure 5 5 5 5 5
Multiple organ failure 8 8 8 8 8
Cytotoxics Long Term/High Dose Steroids 4 4 4 4 4
Long Term Anti-inflammatory 4 4 4 4 4
Total Score
Name of Assessing Nurse
Signature
Designation

Scores can be discounted after 48hrs provided patient is recovering normally

Waterlow Score: 10+ AT RISK 15+ HIGH RISK 20+ VERY HIGH RISK
WR1992~Waterlow Risk Assessment Score~Version 5~Page 1 of 2
 Affix Patient Label here or record
SKIN ASSESSMENT
NAME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NHS NO:
HOSP NO:
D.O.B: D D M M Y Y Y Y MALE FEMALE WARD_____________________ CONS_______________________

In the nurse’s professional judgement full skin assessment is not required for the following reasons
(please tick where appropriate)

1. Fit 2. Healthy 3. Independently mobile 4. Well nourished 5. Unable to assess

6. Patients states they do not have any skin lesions/wounds 7. Patient refuses assessment
However, if the patient’s condition changes for any reason the patient must be re-assessed.
Type of Wound (tick): Diabetic Traumatic Leg Ulcer Surgical Pressure Damage
SITE Wound size - length, width If pressure damage, give category
and depth in cm of damage - 1, 2, 3 or 4

Sacrum

Hip LEFT

Hip RIGHT

Buttock LEFT

Buttock RIGHT

Ankle LEFT

Ankle RIGHT

Heel LEFT

Heel RIGHT

Elbow LEFT

Elbow RIGHT

Head & Face

Other -
(please specify)

If wound present, please complete wound assessment chart and commence appropriate care plan.

Incident Form (Datix) to be completed for all Category 1-4: Date: _______________ Web No:______________
Grade 3/4 RCA to be commenced for all hospital acquired pressure ulcers: Date: ___________________

Name of Assessor: ____________________________ Signature: ___________________________________

Date: _______________________________________ Designation: _________________________________

WR1992~Waterlow Risk Assessment Score~Version 5~Page 2 of 2