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Overview :
The Waterlow Pressure Sore Risk Scale can be used to assess
a patient for the risk of developing a pressure sore. This can be used to help
guide treatment and preventive measures.
Parameters:
(1) age
(2) sex
(3) body build
(4)appetite
(5) continence of urine and feces
(6) mobility
(7) skin appearance in risk areas
(8) special risks
(8a) disorders associated with
tissue malnutrition
(8b) neurological deficits
(8c) medication
(8d) recent surgery or trauma
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Parameter
|
Finding
|
Points
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sex
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female
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2
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male
|
1
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age
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14 - 49
|
1
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50 - 64
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2
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65 - 74
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3
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75 - 80
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4
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>= 81
|
5
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build, weight for height
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average
|
0
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above average
|
1
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|
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obese
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2
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below average
|
3
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appetite
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average
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0
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poor
|
1
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nasogastric (NG) tube
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2
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fluids only
|
2
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nothing by mouth, anorexic
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3
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continence
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complete (urine and stool)
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0
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catheterized and continent feces
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0
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occasionally incontinent
|
1
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catheterized and incontinent feces
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2
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doubly incontinent
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3
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mobility
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fully
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0
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restless or fidgety
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1
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apathetic
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2
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restricted
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3
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inert or in traction
|
4
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chair-bound
|
5
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skin type, visual appearance in risk areas
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healthy
|
0
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tissue paper
|
1
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dry
|
1
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edematous
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1
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clammy
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1
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discolored
|
2
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broken spot
|
3
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where:
• NG tube and
fluids only are one entry in the original table
• complete
continence and catheterized with fecal continence are one entry in the original
table
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Special Risk
Factors
|
Findings
|
Points
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terminal cachexia
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|
8
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cardiac failure
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|
5
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peripheral vascular disease
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|
5
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anemia
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|
2
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smoking
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1
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neurological deficit
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moderate
|
4
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moderate-to-severe
|
5
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severe
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6
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major surgery or trauma
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orthopedic, below waist or spinal
|
5
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on table > 2 hours
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5
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medication
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steroids, cytotoxic agents, high dose anti-inflammatory
agents
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4
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where:
• The original
table had a category Tissue Malnutrition which included terminal cachexia,
cardiac failure, peripheral vascular disease, anemia and smoking. This was
restructured since the instructions implied that each could be scored, rather
than one score being given for the category.
• Neurological
deficits includes strokes, diabetes mellitus, multiple sclerosis, paraplegia
and motor/sensory loss.
score =
= SUM(points for parameters) + SUM(points for special risk
factors)
Interpretation:
• minimum score: 0
• maximum: > 45
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Score
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Risk
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< 10
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low risk
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10 - 14
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at risk
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15 - 19
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high risk
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>= 20
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very high risk
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