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 patients 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 Carers
Medical staff 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 Inpatient acute Inpatient subacute Ambulatory
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 Education package Video
Pamphlet Assessment tool Screening tool
Methodology Resource guide Awareness raising resource (posters etc.)
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? Yes No Unknown Not applicable
Is there a cost for the resource? Yes No Unknown 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
Person-centred
Does the resource adhere to/promote person-centred health care?
principles Yes No Unknown Not applicable
Training
requirements
Is additional training necessary to use the resource?
Yes No Unknown Not applicable
Administration
details
How long does the resource take to use? 0-5 mins 5-15 mins 15-25mins 25mins +

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: Guidelines
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
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
Reliability is the extent to which the tools 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:
http://www.awma.com.au/publications/2007/cpgpppu_v_full.pdf
2. Dealey, C. Risk assessment of pressure sores: a comparative study of Norton and
Waterlow scores. Nursing Standard, 1989; 3:11-12suppl.
3. Papanikolaou P, Lyne P & Anthony D. Risk assessment scales for pressure ulcers: A
methodological review. International Journal of Nursing Studies, 2007;44:285-296.
4. Raycroft-Malone J . Pressure ulcer risk assessment and prevention. Technical reporting.
2000 RCN Publishing, London.
5. Wardman C. Norton v Waterlow. Nursing Times, 1991;87:74-78.
6. Waterlow J . A risk assessment card. Nursing Times 1985;81:24-27.

Waterlow Scale

Build/Weight for Height

Mobility

Special Risks

Average
Above Average
Obese
Below Average
0
1
2
3

Fully
Restless/Fidgety
Apathetic
Restricted
Inert/Traction
Chairbound
0
1
2
3
4
5
Tissue Malnutrition
E.g. Terminal cachexia
Cardiac Failure
Peripheral Vascular Disease
Anemia
Smoking
8

5
5
2
1

Continence

Sex/Age

Neurological Deficit

Complete/Catheterized
Occasional
Cath/Incontinence of Feces
Doubly Incontinent
0
1
2
3

Male
Female
14-49
50-49
65-74
75-80
81+
1
2
1
2
3
4
5
E.g. Diabetes, MS, CVA, Motor/Sensory,
Paraplegic
4-6
Skin Type
Visual Risk Areas

Appetite

Major Surgery/Trauma

Healthy
Tissue Paper
Dry
Oedematous
Clammy (temp)
Discolored
Broken/Spot
0
1
1
1
1
2
3
Average
Poor
NG Tube/Fluids Only
NBM/Anorexic
0
1
2

Orthopaedic below waist, spinal
On Table 2 Hours
5
5
Medication
Steroids, Cytotoxics,
High Dose Anti-Inflam.
4

SCORE 10+ AT RISK 15+ HIGH
RISK
20+ V. HIGH RISK
SEVERAL SCORES PER CATEGORY CAN BE USED; ADD TOTAL