The Waterlow score is a pressure ulcer risk assessment tool used to identify patients at risk of developing pressure damage. It should support, not replace, clinical judgement and regular skin inspection.

📋 What It Assesses

Domain	Why it matters
Build / BMI	Very low or high body weight can increase pressure, friction or poor tissue reserve.
Skin type / visible risk areas	Fragile, broken, dry, oedematous or already damaged skin increases risk.
Sex and age	Older age is associated with thinner skin, reduced mobility and poorer tissue repair.
Continence	Urine or faecal moisture damages skin and increases friction and infection risk.
Mobility	Reduced ability to reposition increases duration of pressure over bony prominences.
Nutrition / appetite	Malnutrition and dehydration impair skin integrity, immunity and wound healing.
Special risks	Includes tissue malnutrition, neurological deficit, major surgery, trauma and some medicines.

📊 Interpretation

Waterlow score	Pressure ulcer risk
<10	Usually not classified as at risk, but continue clinical judgement and skin care.
10–14	At risk
15–19	High risk
≥20	Very high risk

🧠 Clinical Use

Use on admission or first assessment for patients at risk of pressure damage.
Repeat if the patient deteriorates, becomes less mobile, develops incontinence, has surgery, becomes acutely unwell or nutritional intake falls.
Combine with direct skin inspection, pain assessment, mobility review and tissue viability advice where needed.
NICE recognises Waterlow as one of the adult pressure ulcer risk tools used in UK practice, alongside tools such as Braden, Norton and PURPOSE-T.

🛠️ Prevention Measures

Inspect skin regularly, especially sacrum, heels, hips, elbows, ankles and occiput.
Encourage or assist regular repositioning.
Use pressure-redistributing mattresses, cushions or heel protection where indicated.
Manage moisture from continence, sweating or wound exudate.
Optimise nutrition, hydration and protein intake.
Mobilise early where possible.
Refer to tissue viability for existing pressure ulcers or very high-risk patients.

🚨 Red Flags

Non-blanching erythema over a bony prominence.
New skin blistering, purple discolouration or necrosis.
Rapidly worsening pressure damage.
Signs of infection: spreading redness, warmth, swelling, pain, pus, fever or sepsis.
Heel or sacral pain in an immobile patient, even if the skin initially appears intact.

🧠 Exam Pearls

Waterlow estimates pressure ulcer risk, not pressure ulcer grade.
10–14 = at risk, 15–19 = high risk, ≥20 = very high risk.
Higher score means higher risk.
Risk rises with immobility, poor nutrition, moisture, frailty, neurological impairment and acute illness.
Always combine the score with clinical judgement and skin inspection.

✅ Key message: A Waterlow score of 10 or more indicates pressure ulcer risk and should prompt prevention measures such as skin inspection, repositioning, pressure relief and nutrition review.

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Waterlow pressure ulcer risk assessment score

🛏️ Waterlow Score: Pressure Ulcer Risk