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Tool and Resource Evaluation Template

Adapted by NARI from an evaluation template created by Melbourne Health. Some questions may not be applicable to every tool and resource.

Name and purpose Name of the resource: Waterlow Pressure Sore Prevention/Treatment Policy Author(s) of the resource: J. Waterlow. Please state why the resource was developed and what gap it proposes to fill: It was designed as a comprehensive tool which not only outlines a risk assessment scale but also includes preventive aids and treatments. The risk assessment scale is based on the following variables: weight and build, continence, skin type, mobility, gender and age, and appetite. There is also a special section incorporating tissue malnutrition, neurological deficits, surgery/trauma and special medication. These categories enable the assessor to make a detailed assessment of the patient and award several scores in each category to reflect the patient's risk status accurately. With a score >10 the patient is considered at risk; >15 at high risk and >20 at very high risk. The minimum possible score is 1 and the maximum score is 64 (Waterlow, 1985). Target audience (the tool is to be used by) Please check all that apply: Health service users Medical staff Carers Nursing staff Any member of an interdisciplinary team

Medical specialist, please specify: Specific allied health staff, please specify: Other, please specify: Target population/setting (to be used on/in) Is the resource targeted for a specific setting? Please check all that apply: Emergency Department Other, please specify: For which particular health service users would you use this resource (e.g. a person with suspected cognitive impairment)? All in-patients in acute and subacute settings, or residential care settings. Structure of tool Website Pamphlet Methodology Education package Assessment tool Resource guide Video Screening tool Awareness raising resource (posters etc.) Inpatient acute Inpatient subacute Ambulatory

Other, please specify: Please state the size of the resource (e.g. number of pages, minutes to read): 1 page, usually printed in A4 Takes less than one minute to complete once the patient is assessed. Availability and cost of tool Is the resource readily available? Is there a cost for the resource? Yes Yes No No Unknown Unknown Not applicable Not applicable

Please state how to get the resource: The Waterlow scale is provided below: Waterlow Scale It is also available on the internet. See Appendix C in the Australian Wound Management Association guidelines. Applicability to rural settings and culturally and linguistically diverse populations Is the resource suitable for use in rural health services (e.g. the necessary staff are usually available in rural settings)? Yes No Unknown Not applicable Is the resource available in different languages? Yes No Unknown Not applicable for use by staff

Is the content appropriate for different cultural groups? Yes No Unknown Not applicable


Does the resource adhere to/promote person-centred health care?

principles Training requirements Administration details




Not applicable

Is additional training necessary to use the resource? Yes No Unknown Not applicable 0-5 mins 5-15 mins 15-25mins 25mins +

How long does the resource take to use?

Can the resource be used as a standalone, or must it be used in conjunction with other tools, resources, and procedures? Standalone Must be used with other resources, please specify: Can be used with other tools, please specify: Data collection and analysis Are additional resources required to collect and analyse data from the resource? Yes No Unknown Not applicable Guidelines

If applicable, please state any special resources required (e.g. computer software): Sensitivity and specificity Sensitivity is the proportion of people that will be correctly identified by the tool. Specificity is the probability that an individual who does not have the condition being tested for will be correctly identified as negative. Has the sensitivity and specificity of the resource been reported? Yes No Unknown Not applicable If applicable, please state what has been reported: The initial study did not present any data on validity or reliability. Independent assessments of the Waterlow tool demonstrated sensitivity of 98-100%, but specificity as low as 14% (Wardman, 1991; Dealey, 1989). Face Validity Does the resource appear to meet the intended purpose? Yes No Unknown Not applicable Reliability is the extent to which the tool's measurements remain consistent over repeated tests of the same subject under identical conditions. Inter-rater reliability measures whether independent assessors will give similar scores under similar conditions. Has the reliability of the resource been reported? Yes No Unknown Not applicable If applicable, please state what has been reported: In one study, Waterlow scores of student nurses were in agreement for only 12 of 20 patients assessed (60%)(Dealey, 1989). According to Raycroft-Malone (2000), reliability has not been properly assessed. Strengths What are the strengths of the resource? Is the resource easy to understand and use? Are instructions provided on how to use the resource? Is the resource visually well presented (images, colour, font type/ size)? Does the resource use older friendly terminology (where relevant), avoiding jargon? Please state any other known strengths, using dot points: · User friendly. · Quick. · A comprehensive tool which is widely distributed as a laminated pocket sized card, for quick reference. . Limitations What are the limitations of the tool/resource? Is the tool/resource difficult to understand and use? Are instructions provided on how to use the tool/resource? Is the tool/resource poorly presented (images, colour, font type/ size)? Does the tool/resource use difficult to understand jargon? Please state any other known limitations, using dot points: · Criticised for its lack of operational definitions. · Criticised for complexity and over-prediction. · The large number of items on the tool increase potential for poor reliability. · Critical cut-off score is disputable (Papanikolaou et al., 2007). References and Supporting references and associated reading.


further reading 1. Australian Wound Management Association Clinical Practice Guidelines for the prediction and prevention of pressure ulcers. For copy of score see Appendix C. Available at: Dealey, C. Risk assessment of pressure sores: a comparative study of Norton and Waterlow scores. Nursing Standard, 1989; 3:11-12suppl. Papanikolaou P, Lyne P & Anthony D. Risk assessment scales for pressure ulcers: A methodological review. International Journal of Nursing Studies, 2007;44:285-296. Raycroft-Malone J. Pressure ulcer risk assessment and prevention. Technical reporting. 2000 RCN Publishing, London. Wardman C. Norton v Waterlow. Nursing Times, 1991;87:74-78. Waterlow J. A risk assessment card. Nursing Times 1985;81:24-27.

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Waterlow Scale

Build/Weight for Height Average Above Average Obese Below Average 0 1 2 3 Mobility Fully Restless/Fidgety Apathetic Restricted Inert/Traction Chairbound Sex/Age Male Female 14-49 50-49 65-74 75-80 81+ Appetite Average Poor NG Tube/Fluids Only NBM/Anorexic 0 1 2 3 4 5 1 2 1 2 3 4 5 0 1 2 Special Risks Tissue Malnutrition E.g. Terminal cachexia Cardiac Failure Peripheral Vascular Disease Anemia Smoking Neurological Deficit E.g. Diabetes, MS, CVA, Motor/Sensory, Paraplegic 8 5 5 2 1 4-6

Continence Complete/Catheterized Occasional Cath/Incontinence of Feces Doubly Incontinent

0 1 2 3

Skin Type Visual Risk Areas Healthy Tissue Paper Dry Oedematous Clammy (temp) Discolored Broken/Spot

0 1 1 1 1 2 3

Major Surgery/Trauma Orthopaedic ­ below waist, spinal On Table ­ 2 Hours

5 5

Medication Steroids, Cytotoxics, High Dose Anti-Inflam.








Waterlow Scale

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