Waterlow score explained: how the Waterlow assessment works, with a template

The Waterlow score is a pressure ulcer risk assessment that adds up points across seven areas: build and weight for height, continence, skin type, mobility, sex and age, appetite, and a group of special risks covering tissue malnutrition, neurological deficit, major surgery or trauma, and medication. A total of 10 or more means the person is at risk, 15 or more means high risk, and 20 or more means very high risk. It was developed by Judy Waterlow, a nurse, in the 1980s and it remains the most widely used tool in UK care homes.

The short answer

A Waterlow assessment takes about five minutes once you know the person. You score each section from the chart, add the numbers, and read off the risk band. The score then drives the plan: what surface the person lies and sits on, how often they are repositioned, how their skin is checked, how their continence and nutrition are managed, and when they are referred. It is done on admission, at least monthly, and whenever the person's condition changes. The number on its own is not the point. The point is that a score of 18 should look different in the care plan and the daily log from a score of 8, and that the score is reviewed the week the person gets a chest infection, not three months later. The sections below take each part of the Waterlow scale in turn, then work through an example, and finish with a template and a checklist.

What is the Waterlow assessment and where does it come from?

Judy Waterlow developed the score in 1985 while working as a clinical nurse teacher, after finding that the earlier Norton scale missed many patients who went on to develop pressure damage. She added nutrition, skin condition, and a set of special risk factors, and produced the laminated card that most nurses of a certain age still recognise. The tool was revised in 2005 and that version is the one in common use.

The Waterlow score is one of several validated tools. The Braden scale is used in some hospitals and internationally, and NHS England developed the PURPOSE T tool, which some trusts and homes have adopted. NICE clinical guideline CG179 on pressure ulcers does not name a tool; it says a validated scale should be used to support clinical judgement, not replace it. For most care homes the practical position is that Waterlow is what the local tissue viability service expects to see, and what most staff are trained on.

At a glance: the Waterlow score chart

Always score from the printed chart or a system that reproduces it, not from memory. The numbers above are the commonly used 2005 values; check them against your own chart.

Section 1: build and weight for height

This section uses BMI. Average build, a BMI of 20 to 24.9, scores 0. Above average scores 1. Obese, a BMI of 30 or more, scores 2. Below average, a BMI under 20, scores 3. Notice that being underweight scores more than being obese, because a thin person has less padding over bony prominences, but both directions score, because a heavy person is harder to reposition and more likely to develop moisture damage in skin folds.

Use the same monthly weight you use for the MUST score, and the same height. If the person cannot be weighed, use the MUST alternative measurements and record which was used. A BMI that has changed since the last Waterlow is a reason to redo the whole assessment, not just this section.

Section 2: continence

Complete continence, or a urinary catheter that is managed well, scores 0. Urinary incontinence scores 1. Faecal incontinence scores 2. Doubly incontinent scores 3. The reason is moisture: skin that is wet, and skin exposed to faeces, breaks down far more easily, and moisture-associated damage is often the first stage of a pressure ulcer.

Score what is actually happening, not what the continence assessment says should be happening. A person who is continent by day and wet every night is incontinent for this purpose. Where continence has changed recently, that is a reason to look for a cause, usually infection, constipation or a new medicine, and to redo the score.

Section 3: skin type and visual risk areas

This is the section that needs eyes on skin. Healthy skin scores 0. Tissue paper skin, dry skin, oedematous skin, and clammy skin or a raised temperature each score 1, and more than one can apply. Discoloured skin, meaning a category 1 pressure ulcer or non-blanching redness, scores 2. Broken skin or a spot, meaning a category 2 to 4 pressure ulcer, scores 3.

Look at the sacrum, the heels, the hips, the elbows, the shoulder blades, the back of the head, and anywhere a device such as a mask, a catheter tube or a splint touches. Record what you see on a body map. Non-blanching redness is the warning: press the red area lightly, and if it does not go pale and then return, the tissue underneath is already damaged. That finding changes the care plan today, not at the next review.

Section 4: mobility

Fully mobile scores 0. Restless or fidgety scores 1, which surprises people until they think about friction and shear from constant small movements. Apathetic, meaning the person can move but does not, scores 2. Restricted, meaning the person needs help to move, scores 3. Bedbound or in traction scores 4. Chairbound scores 5.

Chairbound scores higher than bedbound because sitting concentrates the body's weight on a small area of the sacrum and ischial tuberosities, and because people in chairs are moved less often than people in beds. A person who sits in the lounge all day and is helped to bed at night is chairbound for Waterlow purposes. The score should prompt the question of how long they sit without a change of position and what they are sitting on.

Section 5: sex and age

Male scores 1 and female scores 2. Age 14 to 49 scores 1, 50 to 64 scores 2, 65 to 74 scores 3, 75 to 80 scores 4, and 81 and over scores 5. These are fixed factors and they mean that a woman of 82 starts with 7 before anything else is scored. That is deliberate. Older skin is thinner, less elastic and slower to heal, and the tool is built to reflect that.

The practical consequence is that almost every resident in a nursing home for older people will score at least 10, and many will score 15 or more. That is not a flaw; it is the reason the plan matters more than the number. Two residents with the same score can need very different care, and the sections that produced the score tell you which.

Section 6: appetite and nutrition

The original chart scores appetite: average 0, poor 1, nasogastric tube or fluids only 2, nil by mouth or anorexic 3. The 2005 revision replaces this with a short nutrition screen that asks about recent unplanned weight loss and whether the person is eating poorly or lacks appetite, and converts the answers into a score. Either version is acceptable; use whichever your chart shows and be consistent.

In practice the MUST score tells you most of what you need here. A person at medium or high MUST risk will score in this section, and the nutrition plan that follows the MUST score is also part of the pressure ulcer plan. The MUST guide covers the screening in detail. Poor nutrition is one of the most modifiable risk factors on the whole chart, which is why the dietitian is often the most useful referral for a person with a rising Waterlow. The food and fluid chart guide covers the monitoring that follows.

Section 7: special risks

The special risks are where the score can jump. Tissue malnutrition covers terminal cachexia (8), multiple organ failure (8), single organ failure such as heart, kidney or respiratory failure (5), peripheral vascular disease (5), anaemia (2) and smoking (1). Neurological deficit covers diabetes, multiple sclerosis, stroke, motor or sensory loss and paraplegia, scored 4 to 6 depending on severity. Major surgery or trauma covers orthopaedic surgery below the waist or spinal surgery (5), and time on the operating table over two hours (5) or over six hours (8), applied for a period after surgery. Medication covers cytotoxics, long-term or high-dose steroids and anti-inflammatories (4).

Score every one that applies. A person with diabetes, heart failure and on steroids will pick up 13 or more in this section alone, before anything about their mobility or skin is considered. That is right: those are the people who develop pressure ulcers fastest and heal slowest. Check the medical history and the medicine list rather than relying on memory, because a diagnosis of peripheral vascular disease or a long-term steroid is easy to overlook.

Adding up and reading the Waterlow risk bands

Add every section. A total of 10 or more means at risk. 15 or more means high risk. 20 or more means very high risk. Below 10 is not no risk; it means the tool has not flagged a heightened risk, and clinical judgement still applies.

Record the total and the score for every section, with the date and the name of the assessor. The sections are what make the score useful. A 16 that comes mostly from age, sex and a chairbound score is a mobility and surface problem. A 16 that comes from a category 2 ulcer, faecal incontinence and poor nutrition is a wound, a continence and a dietitian problem. Same number, different plan.

Worked example: Edith

Edith is 83 and lives in a nursing home. She has had a stroke with left-sided weakness, is helped from bed to chair each morning and sits in the lounge until after tea, and is helped back to bed. Her BMI is 19. She is incontinent of urine at night and uses pads. Her skin is dry and thin, with no redness. She eats about half of each meal and her MUST score is 1. She has type 2 diabetes managed with tablets. She takes no steroids.

1. Build and weight. BMI 19, below average: 3.
2. Continence. Urinary incontinence: 1.
3. Skin. Dry: 1. Tissue paper: 1. Total 2.
4. Mobility. Chairbound: 5.
5. Sex and age. Female: 2. Age 81 and over: 5. Total 7.
6. Appetite. Poor: 1.
7. Special risks. Neurological deficit, stroke and diabetes: 5. No tissue malnutrition factors, no surgery, no medication factors.
8. Total. 3 + 1 + 2 + 5 + 7 + 1 + 5 = 24. Very high risk.

Edith's score is driven by her mobility, her age, her nutrition and her stroke. The plan that follows is about the chair she sits in and for how long, a pressure-relieving cushion and mattress, a repositioning routine through the day, skin checks at every care intervention, a nutrition plan with the dietitian, night continence care that keeps her skin dry, and a referral to the tissue viability nurse for advice. Her score will be repeated monthly and immediately if she becomes unwell.

What the score should change

The assessment is only worth doing if the plan changes with it. At risk, 10 to 14: a pressure-reducing foam mattress and cushion, encouragement to change position, skin checks daily, nutrition and continence reviewed, and a repeat monthly. High risk, 15 to 19: a higher-specification foam or alternating mattress, a pressure-relieving cushion, a written repositioning schedule with times, skin checks at every intervention and recorded on a body map, a nutrition plan, continence care that keeps skin dry, and a repeat at least monthly and after any change. Very high risk, 20 or more: an alternating pressure mattress or equivalent, heel offloading, a repositioning schedule of two to four hours depending on the person and the surface, skin checks recorded each time, referral to tissue viability, a dietitian, and a weekly review.

These are the common arrangements; your local tissue viability service will have its own guidance and it takes precedence. The point is that the care plan says which surface, how often, who checks and where it is recorded, and the daily log shows it happening.

Recording the Waterlow: what the record needs

For each assessment: the date, the assessor, the score for each section, the total, the risk band, the equipment in place, the repositioning schedule, the skin check findings on a body map, the referrals made, and the next review date. Keep every version so the trend is visible: a person who has gone from 12 to 18 over three months has had something happen to them, and the record should show what.

A scored, versioned risk assessment does this automatically: each new score is a new version, the old one is kept, and the change is visible. On paper, keep the assessments in date order in the file and write the previous score at the top of each new one. Kiwi versions every risk assessment this way and keeps the PEEP alongside; whichever system you use, the history should be one click or one page turn away. Either way, the care plan skin section references the current score and the current plan.

How often to reassess

On admission, within six hours in a nursing home and within the first day in a residential home. Then at least monthly. Then again whenever the person's condition changes: an infection, a fall, a period in bed, a hospital admission and return, a change in continence, a change in mobility, a new medicine, weight loss, or any redness found at a skin check. The trigger for reassessment is change, not the calendar.

A monthly reassessment that is done on the same day as the MUST screen, using the same weight, is efficient and makes the two scores easy to read together. Build it into the weighing day.

Linking Waterlow to the daily log and the body map

The score sets the plan; the daily log shows it happening. For anyone at high or very high risk, the log should show each repositioning with the time and the position, each skin check with the finding, and the equipment in use. A body map records any redness, its location, whether it blanches, its size, and a photograph where consented and appropriate. That record is what shows a category 1 area being caught and reversed, or shows that the schedule was not followed on the shift where the ulcer began.

A daily log with body maps and photographs makes this quick enough to do at every intervention. On paper, a repositioning chart and a body map in the room, filed monthly, do the same job. What does not work is a plan that says two-hourly repositioning and a log that says nothing about it.

When a pressure ulcer is found

Any pressure ulcer of category 2 or above is recorded as an incident, reported to the manager, categorised using the international classification, photographed with consent, referred to the tissue viability service or GP, and followed by a review of the Waterlow score and the plan. A category 3 or 4 ulcer, or an ulcer that developed in the home, is a safeguarding consideration and in many areas must be reported to the local authority and notified to CQC. Check your local safeguarding threshold.

The review asks whether the plan was right and whether it was followed. Both questions matter. A plan that was right and not followed is a training and staffing question. A plan that was followed and was not enough is an assessment question, and the score should have been revisited earlier. The pressure ulcer prevention guide covers the full prevention and response process.

Waterlow in learning disability and mental health services

Younger, mobile people score low on Waterlow, and that can produce a false sense of security. Risk in these services concentrates in a few people: those with severe physical disability, those who sit for very long periods, those with poor nutrition, those with diabetes or neurological conditions, and those who are sedated or immobile during an illness. Screen everyone on admission, and then screen the people with risk factors monthly and everyone else at review or when something changes.

A person who refuses skin checks or repositioning may have capacity to do so, and the refusal is recorded with the risk explained and the offer repeated. Where the person lacks capacity, a best interests decision covers the care, and the least restrictive approach is still the one that keeps the skin intact.

Waterlow template

A usable template has the following headings, in this order, on one page.

• Name, date of birth, date of assessment, assessor, previous score and date.
• Build and weight for height: BMI, source of weight and height, score.
• Continence: what is happening, score.
• Skin type and visual risk areas: findings by site, body map reference, score.
• Mobility: description, score.
• Sex and age: score.
• Appetite or nutrition screen: MUST score reference, score.
• Special risks: each factor present, score.
• Total and risk band.
• Plan: surface in bed, surface in chair, repositioning schedule, skin check frequency and where recorded, continence plan, nutrition plan, referrals.
• Next review date and trigger for earlier review.
• Signature of assessor and of the nurse or manager reviewing.

The Waterlow audit checklist

• Every resident has a Waterlow score dated within the last month, or a documented reason.
• Every score shows the section scores, not only the total.
• Every score of 10 or more has a plan that names the surfaces, the schedule and the checks.
• Every score of 15 or more has a repositioning record in the daily log that matches the plan.
• Every skin check finding is on a body map.
• Every resident whose condition changed this month has been reassessed.
• Every category 2 or above ulcer has an incident record, a referral and a plan review.
• The equipment in the room matches the equipment in the plan.

Record the audit with the date, the findings and the actions, and keep it with the other clinical audits so the evidence is in one place when it is asked for. If you want to see scored, versioned Waterlow assessments linked to body maps in a single record, book a demo.

Common mistakes

• Scoring from memory. The values are misremembered and the total is wrong.
• Total without sections. Nobody can tell what is driving the risk, so the plan is generic.
• Monthly by calendar, not by change. The chest infection in week two is not reassessed until week six.
• Plan does not match the score. A 22 on a standard foam mattress with no repositioning schedule.
• Log does not match the plan. Two-hourly on paper, nothing recorded on the shift.
• Skin not looked at. The skin section is scored healthy because nobody checked the heels.
• Special risks missed. The diabetes and the steroid are in the medical notes and not on the score.
• Low score treated as no risk. The younger mobile resident who spent a week in bed with flu and was never rescored.

What good looks like on inspection day

The inspector asks how the home prevents pressure ulcers. The nurse shows the Waterlow for a resident at very high risk: monthly scores for a year, each with section scores, the total rising after a hospital admission in spring and falling again as she recovered. The plan names the alternating mattress and the cushion, both of which are in the room. The repositioning schedule is three-hourly by day and four-hourly at night, and the daily log shows each one with a time and a position. The body map from this morning shows heels and sacrum checked, no redness.

The inspector asks about the last pressure ulcer in the home. The manager shows the incident record for a category 2 on a heel, found at a routine check, photographed, referred to tissue viability the same day, the Waterlow redone that afternoon with the score going from 14 to 19, the plan changed to add heel offloading, and the wound healed in three weeks with the body maps showing it. The safeguarding consideration is recorded with the decision and the reason.

That is inspection-ready evidence: not a home with no pressure damage, but a home where the risk is scored properly, the plan matches the score, the log matches the plan, and when damage does happen it is found early and dealt with.

Final conclusion

The Waterlow score is seven sections added together, and the arithmetic is the easy part. The value is in scoring from the chart with the person in front of you, recording the sections and not just the total, redoing it when something changes rather than when the calendar says so, and making the care plan and the daily log show a plan that matches the number. A score of 24 on a standard mattress with no repositioning record is not an assessment; it is a warning nobody read. Do the assessment, act on it, record the action, and the tool does what Judy Waterlow built it to do: it stops the ulcer before it starts.

Frequently asked

What is a Waterlow score?

A Waterlow score is a pressure ulcer risk assessment that adds points across seven areas: build and weight for height, continence, skin type, mobility, sex and age, appetite, and special risks such as tissue malnutrition, neurological deficit, surgery and medication. A total of 10 or more is at risk, 15 or more high risk, and 20 or more very high risk.

How is the Waterlow score calculated?

Score each section from the printed chart: BMI (0 to 3), continence (0 to 3), skin type (0 to 3, more than one can apply), mobility (0 to 5), sex (1 or 2) plus age (1 to 5), appetite (0 to 3), and every special risk that applies (1 to 8 each). Add them all. Record the section scores as well as the total, because the sections tell you what is driving the risk.

What does a Waterlow score of 15 mean?

A score of 15 to 19 is high risk. The plan should include a higher-specification foam or alternating mattress, a pressure-relieving cushion, a written repositioning schedule, skin checks at every care intervention recorded on a body map, a nutrition plan and continence care that keeps the skin dry, and reassessment at least monthly and after any change in condition.

How often should a Waterlow assessment be done in a care home?

On admission, within six hours in a nursing home and within the first day in a residential home, then at least monthly, and again whenever the person's condition changes: infection, a fall, time in bed, a hospital stay, a change in mobility or continence, weight loss, or any redness found at a skin check. Change is the trigger, not the calendar.

Why does chairbound score higher than bedbound on the Waterlow scale?

Sitting concentrates the body's weight on a small area over the sacrum and the sitting bones, and people in chairs are usually moved less often than people in beds. Chairbound scores 5 and bedbound scores 4 for that reason. A person who sits in the lounge all day and is helped to bed at night is chairbound for Waterlow purposes.

What is the difference between Waterlow and Braden?

Both are validated pressure ulcer risk tools. Waterlow adds points across seven areas including special risks, with higher totals meaning higher risk. Braden scores six areas with lower totals meaning higher risk and is more common internationally and in some hospitals. NICE CG179 does not name a tool; it requires a validated scale used with clinical judgement. Most UK care homes use Waterlow because local tissue viability services expect it.

Does a low Waterlow score mean no risk?

No. A score under 10 means the tool has not flagged heightened risk, but clinical judgement still applies. Younger, mobile people in learning disability and mental health services usually score low, and the risk appears when they are ill, immobile or sedated for a period. Reassess as soon as circumstances change rather than waiting for the monthly date.

Sources

• NICE clinical guideline CG179 Pressure ulcers: prevention and management
• Judy Waterlow: The Waterlow Score card and manual, 2005 revision
• NHS England: Pressure ulcer core curriculum and Stop the Pressure programme
• NHS Improvement: Pressure ulcers, revised definition and measurement framework
• BAPEN: MUST calculator and explanatory booklet
• CQC: guidance on Regulation 12 safe care and treatment, including pressure area care
• Tissue Viability Society: pressure ulcer prevention resources