Read Waterlow Pressure Ulcer Risk Assessment Tool text version

Affix Patient ID Sticker

Hospital / Facility______________________

WATERLOW PRESSURE ULCER RISK ASSESSMENT TOOL

1. Circle each score. 2. Several scores per category can be calculated. 3. Add totals to obtain risk score.

Has the patient previously had a pressure ulcer? (Please circle ) SEX / AGE BUILD / WEIGHT FOR HEIGHT Yes No SPECIAL RISKS TISSUE MALNUTRITION

Male Female 14-49 50-64 65-74 75-80 81+

MOBILITY

1 2 1 2 3 4 5

Average Above average Obese Below average BMI= WT (Kg) HT (m2 ) 0 1 2 3 4 5 4

BMI (20-24.9) (25-29.9) > 30 < 20 Weight = Height =

0 1 2 3

Terminal cachexia Multiple organ failure Single organ failure (resp. renal, cardiac & liver) Peripheral vascular disease Anaemia (Hb<8) Smoking

NEUROLOGICAL DEFICIT

8 8 5 5 2 1 4- 6

WATERLOW PRESSURE ULCER RISK ASSESSMENT

CONTINENCE

Fully mobile Restless /fidgety Apathetic Restricted Bed bound (eg traction) Chair bound (eg wheelchair)

MEDICATION

Complete/catheterised Urine incontinence Faecal incontinence Urinary and faecal (double) incontinence

SKIN TYPE VISUAL RISK AREAS

0 1 2 3

Diabetes, MS, CVA, Motor/sensory paraplegia (maximum of 6 for this category)

MAJOR SURGERY OR TRAUMA

0 Orthopaedic/Spinal Healthy 1 On table > 2hrs (in past 48hrs) Tissue paper 1 Dry & or Itching > 6 hrs (in past 48hrs) 1 Oedematous 1 Clammy, pyrexia 2 Discoloured Stage 1 (maximum score of 4 for one Nutritional Score: Pressure Ulcer Stage 2,3 or 4 3 or more in this category) Total Score: 10+ At risk 15+ At high risk 20+ Very high risk Cytotoxics Steroids Anti-inflammatory Anti-Coagulant Completed by (Print name): Signature: Date: / /

5 5 8

Malnutrition Screening Tool (MST) ­ Circle scores and add for a total score

A. Has the patient lost weight recently without trying? Yes No Unsure - Go to question B - Go to question C - Score 2 and go to question C B. How much weight has the patient lost? 0.5-5.0kg 5.0-10.0kg 10.0-15.0kg > 15.0 kg Unsure Score 1 Score 2 Score 3 Score 4 Score 2 C. Has the patient been eating poorly because of a decreased appetite? No Yes Nutritional Score: - Score 0 - Score 1

If the patient's score is 2 or more please refer them to a Dietitian: Dietitian: Date referred: / / Signature:

DOCUMENT THE RISK ASSESSMENT IN THE MEDICAL RECORD CHART Waterlow Tool - modified and reproduced with permission of Judy Waterlow in 2003.

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Waterlow Pressure Ulcer Risk Assessment Tool

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Waterlow Pressure Ulcer Risk Assessment Tool