Waterlow Score: What It Means and How to Use It in Care

The Waterlow score is a pressure ulcer risk assessment tool. You score a person on build, continence, skin, mobility, sex and age, nutrition and a set of special risks, then add the numbers up. A total of 10 or more means at risk, 15 or more high risk and 20 or more very high risk. It supports clinical judgement; it doesn't replace it.

Where the Waterlow score comes from

Judy Waterlow designed the tool in 1985, while working as a clinical nurse teacher, and revised it in 2005. The score card is copyright, so we describe it here rather than reproduce it. You can download the card free, and buy the manual, from the official Waterlow website.

NICE's guideline on pressure ulcers (CG179) names Waterlow alongside the Braden and Norton scales as validated tools to use "to support clinical judgement". That phrase matters.

What the Waterlow score measures

The card groups risk factors into sections. In each one you ring the score that fits the person, then total them. Some sections allow more than one score.

• Build and weight for height, based on body mass index.
• Continence, because damp skin breaks down more easily.
• Skin type over the areas at risk, such as heels, hips and the base of the spine.
• Mobility: how well the person moves and changes position for themselves.
• Sex and age.
• Malnutrition screening: short questions about recent weight loss and eating poorly.
• Special risks: tissue malnutrition, neurological deficit, major surgery or trauma, and certain medicines such as long-term steroids or cytotoxic drugs.

Weight loss and poor intake leave skin less able to cope with pressure. If you also use the MUST malnutrition screening tool, the two assessments should tell a consistent story.

What the total means

• 10 or more: at risk
• 15 or more: high risk
• 20 or more: very high risk

The number on its own does nothing. What counts is the plan that follows: the right mattress and cushion, repositioning, skin checks at every personal care, continence care, and support to eat and drink. As a minimum, NICE says adults at risk should change position at least every six hours, and adults at high risk at least every four. The care plan sets the actual frequency, and many people need more.

Reassess when things change. NICE gives examples such as surgery, a condition getting worse, or a change in mobility. A chest infection that keeps someone in bed for a week can move them up a band in days.

The limits of the Waterlow score

• It's a score, not a skin check. Someone can score 9 and already have a red heel. The skin you see beats the number on the chart.
• Totals hide detail. The European Pressure Ulcer Advisory Panel (EPUAP) says risk tools should support clinical judgement, not replace it, and that total scores alone aren't enough to guide prevention. Plan around the factors driving the score.
• Scoring involves judgement. Two staff can ring different boxes for the same person, so train whoever completes it and audit a sample.
• Devices get missed. Oxygen tubing, catheters, splints and tight footwear can cause damage in people who otherwise score low.
• Early damage is harder to see on darker skin. It may look purple, blue or darker rather than red. Check for warmth, firmness, swelling and pain too.

Waterlow, PURPOSE-T and other tools

PURPOSE-T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) was developed by Susanne Coleman, Professor Jane Nixon and colleagues at the University of Leeds and Leeds Teaching Hospitals NHS Trust. A clinical evaluation published in 2018 supported its use in practice.

There's no total score. Staff screen first, then assess movement, skin, previous pressure ulcers, medical devices, circulation, sensation, moisture and diabetes. The result is colour coded: green (not currently at risk), amber (at risk) or red (existing pressure damage or scarring from a previous ulcer). The University of Leeds PURPOSE-T page explains the tool and its terms of use.

The National Wound Care Strategy Programme in England points to PURPOSE-T, and some NHS organisations have adopted it. Many services still use Waterlow. Use the tool in your policy, and use it the same way every time.

Pressure ulcer categories

Damage is categorised using the international system from EPUAP, the US National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance. NHS reporting guidance in England uses "category" rather than "grade".

• Category 1: intact skin with redness, or a colour change on darker skin, that doesn't fade when pressed.
• Category 2: the top layer of skin is broken, as a shallow open sore or a blister.
• Category 3: the ulcer goes through the skin into the fat underneath.
• Category 4: the ulcer exposes muscle, tendon or bone.
• Unstageable: dead tissue covers the base, so the depth can't be seen.
• Deep tissue injury: purple or maroon skin, or a blood-filled blister, where the depth is unknown.

Moisture-associated skin damage, from incontinence or sweat, is recorded separately from pressure damage, though the two often appear together. Damage from a medical device is recorded as device-related.

aSSKINg: turning risk into a plan

Many NHS organisations build prevention plans around aSSKINg, used by the National Wound Care Strategy Programme. You may also see the older SSKIN version.

• a: assess risk
• S: skin assessment and skin care
• S: surface (mattress, cushion and other equipment)
• K: keep moving (repositioning)
• I: incontinence or increased moisture
• N: nutrition and hydration
• g: give information to the person and their family

For the N, our nutrition and hydration training covers what care staff can do day to day.

When to escalate and report

Care staff usually spot problems first, during washing or dressing. Make sure everyone tells the nurse or senior on shift straight away about redness that doesn't fade, broken skin, or a purple or dark patch over a bony area. NHS advice is to get urgent help if the skin is hot, swollen or red, there's pus, a high temperature, or pain that's severe or getting worse.

Record pressure damage through your local incident reporting system, and follow your local policy and the person's care plan on who reviews the wound, such as the GP, district nurse or tissue viability team.

In England, the Department of Health and Social Care's guidance Pressure ulcers: how to safeguard adults says pressure ulcers are mainly a matter for clinical investigation, not automatically a safeguarding enquiry. Severe damage, which may be shown by multiple category 2 or a single category 3 or 4 ulcer, should prompt a decision guide completed by an experienced registered nurse. Where abuse or neglect is suspected, raise a safeguarding concern; the local authority decides whether an enquiry is needed. Scotland, Wales and Northern Ireland have their own safeguarding arrangements.

How Kasorb can help

Our wound care and pressure ulcer prevention training teaches care staff to protect skin, spot early pressure damage, support repositioning and simple wound care, and know when to escalate to a nurse. It covers the pressure ulcer categories, risk tools such as Waterlow and PURPOSE-T, the SSKIN approach, pressure-relieving equipment, moisture-associated skin damage and reporting, including when to raise a safeguarding concern. Your trainer has used these skills for real.

We run it at your premises anywhere in the UK or live online, for up to 12 staff, at one price for the group. Certificates are emailed the next day. Nurses who assess wounds and choose dressings should see our tissue viability training.

FAQs

What is a good Waterlow score?

A lower score means lower risk, and a total under 10 sits below the 'at risk' band. That isn't a clean bill of health. If someone has redness that doesn't fade or a sudden drop in mobility, act on what you see and tell the nurse.

What does a Waterlow score of 15 mean?

A total of 15 to 19 puts the person in the 'high risk' band. It calls for a written prevention plan covering skin checks, mattress and cushion, repositioning, continence care and nutrition, reviewed regularly. Twenty or more is 'very high risk'.

How often should a Waterlow score be done?

Follow your local policy. NICE says risk should be reassessed when the person's clinical status changes, for example after surgery, when a condition gets worse or when their mobility changes. Most services also set a routine review.

Who can complete a Waterlow assessment in a care home?

Whoever your policy names, often a registered nurse or a trained senior carer. They need to know the tool well and look at the person's skin, not just their notes. Care staff help by reporting changes in skin, continence, eating and mobility.

Is Waterlow being replaced by PURPOSE-T?

Some NHS organisations in England have moved to PURPOSE-T, and the National Wound Care Strategy Programme points to it. Others still use Waterlow, Braden or Norton. Use the tool your organisation has chosen and train staff to use it consistently.