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An Examination of the Waterlow Scoring System for Pressure Ulcer Prevention

The aim of this concise paper is to provide an understanding of the Waterlow Scoring System's role in enhancing patient care and preventing the development of these debilitating injuries.

A graphic example of a pressure ulcer

Pressure ulcers, colloquially known as pressure sores or bedsores, represent localised injuries to the skin and underlying tissue, typically occurring over bony prominences due to prolonged pressure or friction. These injuries should not be underestimated or treated as trivial; they can be very significant and concerning injuries causing pain, immobilisation, severe infections, psychological distress, and hindering the healing process. In primary and secondary healthcare, preventing pressure ulcers is of utmost importance, and the Waterlow Scoring System stands as a pivotal tool in this pursuit. Developed in response to the rising incidence of pressure ulcers, this comprehensive risk assessment system plays a vital role in identifying individuals at risk and guiding tailored preventative interventions. This exploration delves into its historical evolution, key components, scoring methodology, interpretation of scores, application in clinical practice, as well as its limitations and criticisms.

The Historical Evolution of the Waterlow Scoring System

Originating in the 1980s, a period marked by heightened awareness of pressure ulcers' impact on patient well-being, the Waterlow Scoring System emerged as a response to the need for a systematic approach to assess and mitigate pressure ulcer risks. Introduced in the United Kingdom this standardised risk assessment tool reflects a commitment to proactive healthcare.

Emergence and Early Adoption

A photo of Judy Waterlow

Judy Waterlow MBE (Deceased 2021), a distinguished nurse (trained at St Thomas’s) and healthcare educator, developed the system, establishing foundational principles for a comprehensive risk assessment. Its early adoption marked a transformative phase in healthcare practices, setting the stage for a standardised approach to pressure ulcer prevention.

Founding Principles

Built on clinical expertise, the Waterlow Scoring System's holistic approach considers a range of patient-specific factors contributing to pressure ulcer risk. Factors such as age, sex, BMI, skin type, continence, mobility, nutrition, and special risk factors were integrated into its design, reflecting a nuanced understanding of pressure ulcer susceptibility.

Importance of Pressure Ulcer Prevention

Recognition of the paramount importance of preventing pressure ulcers is essential. These injuries, if not addressed promptly, can lead to severe consequences, including pain, infections, and delayed recovery. Early assessment and preventative measures are crucial components of a comprehensive strategy to mitigate these risks.

Key Components of the Waterlow Scoring System

A chart of the Waterlow Scoring System

Taking a holistic approach, the Waterlow Scoring System evaluates various factors, including age, sex, BMI, skin type, continence, mobility, nutrition, and special risk factors. Each component contributes to a comprehensive assessment, forming the basis for tailored interventions to prevent pressure ulcers.

Scoring Methodology

Understanding the scoring methodology is vital for the effective use of the Waterlow Scoring System. Each factor receives a numerical score, and the total Waterlow Score is determined by summing these individual scores. Specifics of scoring key components are as follows:

Age: Age is assigned a numerical value. Typically, older age contributes to a higher score, reflecting the increased vulnerability of elderly individuals to pressure ulcers.

  • BMI (Body Mass Index): BMI is assessed numerically. A lower BMI may indicate malnutrition or frailty, contributing to an elevated Waterlow Score.

  • Skin Type: Skin type is categorised based on its susceptibility to damage. Fragile or very fragile skin types may result in higher scores.

  • Mobility: Mobility is graded on a scale, considering a patient's ability to move independently. Limited mobility contributes to a higher Waterlow Score.

  • Continence: Continence is assessed, and issues such as urinary or faecal incontinence may increase the Waterlow Score.

  • Nutrition: Nutritional status is evaluated, with poor nutrition leading to an elevated score. This component underscores the importance of adequate nourishment in preventing pressure ulcers.

  • Special Risk Factors: Special risk factors, such as pre-existing medical conditions or treatments, are considered individually and contribute to the overall Waterlow Score.

Interpretation of Scores

Once individual scores are determined, the Waterlow Scoring System categorises patients into different risk levels:

  • Low Risk: Individuals with lower total scores fall into the low-risk category. Standard preventive measures are typically sufficient, though continuous monitoring remains crucial.

  • Moderate Risk: Moderate-risk individuals have scores indicating a moderate susceptibility to pressure ulcers. Healthcare professionals must implement targeted preventive measures and maintain vigilant monitoring.

  • High Risk: High-risk individuals, with higher total scores, face a heightened susceptibility to pressure ulcers. Intensive preventive interventions, including frequent repositioning, thorough skin inspections, and specialised support surfaces, are imperative for this group.

Understanding these risk categories guides healthcare professionals in crafting tailored care plans that align with the evolving risks and needs of individuals.

Application in Clinical Practice

In clinical practice, the Waterlow Scoring System serves as a cornerstone for pressure ulcer prevention. Healthcare professionals utilise the scores to craft individualised care plans, implementing targeted interventions to reduce the risk of pressure ulcers. This proactive approach is crucial for providing high-quality patient care. Healthcare establishments should have local policies in place that prescribe the treatment afforded to each of the identified risk groups.

Limitations and Criticisms

If nothing else, the Waterlow score acts as a reminder to practitioners of the importance of pressure ulcer prevention. Over the years, there has been much criticism of the Waterlow score and, in particular, the lack of underpinning research. Here are some other examples of Waterlow score limitations:

  • Subjectivity in Scoring Components: One notable limitation of the Waterlow Scoring System is the subjective nature of certain components. Factors such as skin type and continence, which are subjectively assessed, can introduce variability in scoring. Different healthcare professionals may interpret these factors differently, potentially impacting the overall score.

  • Influence of External Factors: The system may not account for external factors that can influence a patient's risk of pressure ulcers. For example, environmental factors, the quality of healthcare facilities, and variations in healthcare practices can impact the effectiveness of the Waterlow Scoring System in different settings.

  • Limited Consideration of Psychological Factors: The Waterlow Scoring System primarily focuses on physical factors, such as mobility and nutrition, but may not adequately address psychological factors. Mental health, stress, and emotional well-being can also play a role in the development of pressure ulcers, and their omission could be considered a limitation.

  • Static Assessment: The system provides a snapshot assessment at a specific point in time. It may not capture changes in a patient's condition or risk factors over time. A dynamic approach that considers evolving patient characteristics might provide a more accurate representation of pressure ulcer risk.

  • Assumption of Homogeneity within Categories: The categorisation into low, moderate, and high-risk groups assumes homogeneity within each category. However, individuals classified in the same risk category may have diverse characteristics and needs. This lack of granularity can limit the precision of interventions tailored to specific patient profiles.

  • Overemphasis on Physical Factors: While physical factors are crucial contributors to pressure ulcer risk, an overemphasis on these aspects might overshadow the importance of holistic care. Emotional and social factors, as well as the overall patient experience, should be considered to provide comprehensive and patient-centred care.

  • Not a Substitute for Clinical Judgment: The Waterlow Scoring System is a valuable tool, but it should not replace clinical judgment. Healthcare professionals need to use their expertise to assess individual cases, considering nuances that may not be fully captured by the scoring system alone.

Acknowledging these limitations and criticisms is essential for healthcare practitioners to use the Waterlow Scoring System effectively in collaboration with their clinical skills. Supplementing its use with additional assessments and a holistic approach to patient care ensures a more comprehensive strategy in preventing pressure ulcers.


In conclusion, the Waterlow Scoring System emerges as a valuable tool in the prevention of pressure ulcers. Its development, rooted in the 80s, in response to the growing incidence of pressure ulcers, highlights a pivotal moment in healthcare history. Judy Waterlow's vision for a holistic risk assessment tool has since become an integral part of clinical practice, providing a nuanced approach to pressure ulcer prevention. By understanding and utilising the key components, scoring methodology, and interpretation of scores, healthcare professionals can proactively implement individualised care plans. However, the system's journey has not been without challenges. Acknowledging its limitations, from subjective scoring components to the overemphasis on physical factors, is essential for refining its use in diverse healthcare settings.

The remarkable contributions and foresight of Judy Waterlow stand as a testament to the continuous commitment to enhancing patient care and preventing pressure ulcers effectively.

Scott Harding-Lister, The head of practice at Apex Health Assocaites


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