JCN

Edwin Tapiwa Chamanga

discusses the use of tiie
Wateriow assessment tool in
wound management

Key words:
Wateriow assessment tool
f-folistic assessment
Pressure sore prevention

Acknowledgement:
The author would like
acknowledge the contribii'
Mr. Prince Sunkwa-Mills, a stude:
in MSc Health Informatics, who
assisted in some of the research f(
this article.

Edwin Tapiwa Chamanga RGN, BSc

(Hons), (BSc Hons) Specialist Community
Practice (District Nursing), currently reading
for an MSc Skin integrity skills and
treatments is a Tissue Viability Nurse
Specialist, City and Hackney Primary Care
Trust, London
ArUcfe accepted for publication: September 2009

26

WOUND MANAGEMENT

A critical review of the

Wateriow tool

he Wateriow assessment tool

remains the most commonly used
tool for assessing a patient's risk of
developing pressure sores. According to
a random statistical survey conducted on
eight primary care trusts (PCTs) within
the north and east London region it
emerged that six PCTs used the Wateriow
scale assessment tool. These PCTs are not
exclusive and throughout the UK there
are more organisations using the
Wateriow scale assessment tool.
Wateriow (1985) and Hibbs (1985) state
that around 95 per cent of pressure sores
are preventable particularly with the
provision of sophisticated pressure sore
prevention equipment (Beldon et al,
2009). However, this is not the case in
clinical practice as incidents of pressure
ulcers are continuously being reported.
Pressure ulcer development as a result
of poor patient assessment and equipment acquisition remains on the increase
(Moore & Price, 2004; Hampton, 2005).
As a result of increased collaboration
between secondary care trusts and PCTs,
patients are now being discharged into
the community requiring pressure area
care and equipment ordering before
going home. This transition is facilitated
by the use of a similar pressure sore risk
assessment
tools
between
the
discharging hospital and the community.
This article aims to review the Wateriow
scale assessment tool as an effective
measure of a patient's predisposing
factors (risk) to pressure sore development, and as a guide to effective pressure
equipment ordering.

medication the patient will be taking.

Assessing these risk factors for each individual enables practitioners to offer and
deliver person centred care, which is
tailored for individual health care needs
(McCormack, 2003; Parkinson, 2004)

The Wateriow toot

Build/ Weight for Height

The Wateriow scale assessment tool was

introduced into practice in 1985
(Wateriow, 1985). More than two decades
on, it remains the most popularly used
pressure area assessment tool in many
hospitals and PCTs across the country
(Ash, 2002; Defloor & Grypdonck, 2005).
The tool enables patients to be assessed
according to each individual's risk of
developing pressure sores (PancorboHidalgo et al, 2006). It explores the
following risk factors: weight for height
ratio, continence, skin condition,
mobility, sex and age, nutrition, skin
condition, neurological function, major
surgery or trauma and lastly the type of

Wateriow assessment tool highlights the

importance of assessing body build in
relation to patient's risk of developing a
pressure sores. This is important as part
of a patient's total holistic assessment
as it aids patient centred care and the
provision of cost effective pressure
relieving equipment. For all patients
presenting with a body mass index (BMl)
greater than 20 they must have a nutritional assessment screening (National
Institute for Health and Clinical Excellence (NICE), 2006), this can aid pressure
sore prevention by providing necessary
pressure relieving equipment. From the
above it is evident that the Wateriow

(Table 1).

Discussion and critical

evaluations
Wateriow effectively viewed the development of pressure sores as being
influenced by both extrinsic and intrinsic
factors (Wateriow, 1995; Balzer et ai,
2007). The intrinsic factors include age,
malnutrition, dehydration, incontinence,
pre-existing medical cond itions and
certain types of medication. Whereas the
extrinsic factors are considered to be
pressure, shearing and friction which
directly affect skin integrity. Wateriow
(1997; 1998) argued that nursing interventions can effectively alleviate
extrinsic factors, yet in reality most of the
above mentioned intrinsic factors can be
alleviated by nursing interventions such
as multidisciplinary team working apart
from patient's age and medical condition. Comversely, Balzer ct al. (2007)
criticised Waterlow's idea of considering
extrinsic factors as probable causes of
pressure sores, when there are not
considered or mentioned on her assessment form (Table 1 ). There is also a lack of
assessment guidelines or descriptor on
the tool which is a major cri ticsm(Bridel,
1993). As a result, it is difficult to use for
novice clinicians as will be discussed in
subsequent paragraphs.

lournal of Community Nursing

May 2010, volume 24, issue 3

WOUND MANAGEMENT

WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICY

RING SCORES IN TABLE, ADD TOTAL. MORE THAN 1 SCORE/CATEGORY CAN BE USED

BUILD/WEIGHT
FOR HEIGHT
AVERAGE
BMi = 20-24.9
ABOVE AVERAGE
BMi = 25-29.9
OBESE
BMi > 30
BELOW AVERAGE
BMI < 20

0
1
2
3

CONTINENCE

SKIN TYPE
VISUAL RISK
AREAS

HEALTHY
TiSSUE PAPER
DRY
OEDEMATOUS
CLAMMY, PYREXiA
DISCOLOURED
GRADE 1
BROKEN/SPOTS
GRADE 2-4

0
1
1
1
1

MOBILITY

COMPLETE/
CATHETERISED
URiNE INCONT
FAECAL INCONT
URINARY + FAECAL
INCONTiNENCE

0
1
2
3

SCORE

FULLY
RESTLESS/FIDGETY
APATHETiC
RESTRICTED
BEDBOUND
e.g. TRACTION
CHAIRBOUND
e.g. WHEELCHAiR

SEX
AGE

MALE

FEMALE

14-49

50-64

65-74

75-80

81 +

MALNUTRITION SCREENING TOOL (MST)

(Nutrition Vof.15. No.6 1999 - Australia
A - HAS PATiENT LOST
WEIGHT RECENTLY
YES
GO TO B
NO
- GO TO C
UNSURE - G O TOC
AND
SCORE 2

C - PATiENT EATING POORLY

OR LACK OF APPETITE
'NO' = 0; 'YES'SCORE = 1

0
1
2
3
4
5

TISSUE MALNUTRITION
TERMINAL CACHEXiA
MULTiPLE ORGAN FAILURE
(RESP, RENAL. CARDIAC,}

8
8

NUTRITiON SCORE
if > 2 refer for nutrition
assessment / intervention

NEUROLOGICAL DEFICIT
DIABETES, MS, CVA

4-6

MOTOR/SENSORY

4-6

PARAPLEGIA (MAX OF 6)

4-6

AJOR SURGERY or TRAUW A

PERIPHERAL VASCULAR

5
2
1

SMOKING

20+VERY HIGH RISK

SiNGLE ORGAN FAILURE

ANAEMIA ( H b < 8 )

15+ HIGH RISK

SCORE
=1
=2
=3
=4
=2

SPECIAL RISKS

DISEASE

10+AT RISK

B - WEiGHT LOSS
0.5 - 5kg
5-10kg
10-15kg
>15kg
unsure

ORTHOPAEDIC/SPINAL
ON TABLE > 2 HR#
ON TABLE > 6 HR#

5
5
8

MEDICATION - CYTOTOXICS, LONG TERM/HIGH DOSE STEROIDS.

ANTI-INFLAMMATORY
MAX OF 4
# Scores can be discounted after 48 hours provided patient is recovering normaiiy

IS J Waterlow 1985 Revised 2005*

Obtainable from the Nook, Stoke Road. Henlade TAUNTON TA3 5LX
* The 2005 revision iricorporates tfie research undertaken by Oueensland Health.

www.judy-waterlow.co. uk

Table 1: The Wateriow Assessment Tool (adapted from http://www.judy-vaterlow.co.uk).

assessment scale is not a stand alone

screerng tool as it compliments other
nursing assessment tools. Hence the
incorporation of the Malnutrition
Screening Tools (MST) on the assessment
form in Tablel.

Continence

Waterlow assessment tool identified

continence as an aspect that needs to be
assessed when screening patients' risk of
developing pressure sores. It has been
reported that skin integrity is compromised by maceration as a result of both
urine and faecal matter (Low, 199; Finestone et al., 1991). This section of the
assessment tool enables clinicians to
effectively assess patients and prevent
the development of pressure sores.
Skin Type

Worley (2007) observed that the skin as

the largest organ of the human body, is
like any other organ and it is prone to
failure. Therefore, with the ageing and
disease process, human skin condition is
subject to change as noted by Waterlow.
28

She reported that patient's skin type and

visual characteristics are subjected to
multi-factors. Hence, when assessing
patients, nurses are encouraged to
consider all the possible risk factors
which may predispose them to developing pressure sores. However, this
section of the assessment tool is not
specific on the location of the broken skin,
because some patients may have a
broken skin which does not affect their
mobility or any other pressure ulcer risk
related factors. For example, a skin tear of
fragile skin behind the palm, may have
also been highlighted earlier as part of
tissue paper skin, meaning that on this
section a patient will end up with an
unnecessarily higher score.
Waterlow (1995) advocates for staff
training on the use of the tool before it can
be used effectively. However, it is
common practice for nurses to use the
tool without training, therefore it is
unsurprising if difficulties arise when
nurses fail to make the correct distinctions between tissue paper, dry.

oedematous, clammy and pyrexia skin. It

is important to identify the correct skin
type during assessment; this will facilitate the ordering of appropriate pressure
relieving equipment. Due to a lack of
appropriate descriptors of various skin
types, it can be problematic for this
section of the assessment tool to be effectively employed in clinical practice.
MobiHty

Low (1990) argues that any mobility

impairing condition is likely to increase
the development of pressure sores.
Waterlow (1988) accords with this idea,
hence on the assessment tool the risk of
developing pressure sores increases with
every possible restraint on mobility.
Wateriow rated mobility within a range
of 0 to 5 and gave descriptors such as fully
mobile to being chair bound as an
increased risk of developing pressure
ulcers. This is logical and coherent,
however, it would have been helpful if
examples were included to indicate the
term traction, apathetic and what the
term restricted is referring to.

joumal of Community Nursing May 2010, volume 24, issue 3

WOUND MANAGEMENT
Sex/Age

Anthony et al (2003) and Papanikolaou et

al. (2002) suggest that gender should be
removed from the tool as it does not significantly predict the risk of pressure sore
development. However, in a study by
Versluysen (1986) and Bale et al (1995) 327
hospice patients were assessed using the
Norton scale every 48 hours. Results
showed that 21 per cent of women
compared with nine per cent of men
developed pressure ulcers. Though this is
consistent with the Waterlow's scale,
Anthony et al (1998) found in a comparative study of risk scores of 150 wheelchair
users and 9022 hospital inpatients that 45
per cent of males developed ulcers
compared with only 22 per cent of
females. More research is needed to clarify
these discrepancies as the reason remains
unclear (Thompson, 2005). Therefore, it
leaves the application of this section of the
assessment tool questionable.
Evidence suggests that the ageing
process results in a disruption of collagen
fibers (Bendavid et al, 2001). It has also
been noted that with the ageing process
people lose the subcutaneous tissue,
reduction in pain perception and
reduced cell mediated immunity (Levine
et al, 1989). As a result of the ageing
process the skin became less resilient and
regenerative as it was previously, therefore, it warrants the need for pressure
damage risk assessment.
Malnutrition Screening Tool (MST)

It is important that the Watertow

screening tool addresses patient's nutritional habits, as evidence suggests that
dehydration, anaemia, electrolyte imbalance and malnutrition often lead to the
development of pressure sores (Berlowitz
& Wilking, 1989). For instance, patients
with highly exudating ulcers are likely to
lose important nutrients through the
wound exdate (White & Cutting, 2006)
which will result in nutrient deficiency at
cellular level. Therefore, this section ofthe
assessment form is very important as it
highlights the risk factors for patients
developing pressure sores due to a lack of
adequate nutrients.

Special risks
Tissue malnutrition

This section of the tool is quite self

explanatory and user friendly, however,
the only limitation is the use of the word
"terminal cachexia" which may not be

disease'. From the above given definition

the Wateriow scale is repetitive, if a
patient is suffering from "terminal
cachexia", it would have been identified
under the section build or weight for
height section with a body mass index
below average. On the other hand, if a
patient was suffering from chronic
obstructive pulmonary disease (COPD)
they would have not been assessed under
special risks. Yet, evidence and reports
suggests that approximately 30 per cent
ofpatients with COPD lose weight, whilst
some have a tendency of becoming over
weight (NichoUs, 2004; Barnett, 2009).
Out of eight colleagues who were asked
what "terminal cachexia" meant, none of

them were able to give a valid definition.

According to Kelly (2005) this demonstrates that nurses are prepared to ignore
things they do not understand rather than
ask for clarification. This could be true for
many nurses, and if so it means they may
either have at one time unnecessarily over
scored or underscored a patient whilst
using the assessment tool.
The assessment tools also takes into
consideration those patients with
vascular diseases as noted by Vbhra and
McCollum (1994) and Hillan (1999) that
patients with arterial disease have a
greater risk of developing pressure sores,
as a result of compromised local tissue
perfusion. With the increase in vascular
diseases (Rapp, 2009) it is imperative that
this section is also considered on the
assessment tool.
Neurological deficit

Patients with neurological disorders,

such as multiple sclerosis and spinal cord
lesions have an 85 per cent chance of
developing pressure sores (Finestone et
al, 1991; Kranse et al, 2001). In clinical
practice it is important to screen these
patients and reduce their risk of developing pressure sores, by the provision of
appropriate pressure relieving equipment. One of the weaknesses of this
section of the assessment form is its lack
of clarity on risk scoring; it scores risks on
the range of 4 - 6. This scoring can be
confusing even to experienced clinicians.
It is not clear whether one awards a four
if the patient is diagnosed with one of the
listed neurological complications like
diabetes or ii^ the patient becomes
terminal. It is also not clear as to what
score would a patient get if they were
both diabetic and paraplegic.

easily understood and defined by clinical

practitioners, Medline Plus (2009) defines

Major Surgery or Trauma

cachexia as 'a general physical wasting and

malnutrition usually associated with chronic

Studies by Andersen ef al (1982) and

O'Sullivan et al (1997) reported that

30

patients who undergo surgery or suffer

trauma are at risk of developing pressure
sores due to either extended immobilisation or direct tissue damage due to
trauma. The above two mentioned factors
are related to reduced dermal perfusion;
hence Wateriow assesses them as predisposing factors of developing pressure
sores. However, Wateriow scale does not
specify the length of time to be considered
post surgery or trauma that can increase
the risk of developing pressure sores.
Medication

It has been noted that steroids and antiinflammatory

medication
reduces
synovial inflammation, effusion and
pain sensation. As a result this masks the
protective pain mechanism which a
patient would experience (Cox, 1984;
Williams & Wilkins, 1998), Therefore, it is
important that Wateriow considered
these medicines as predisposing factors
for patients developing pressure sores.
With decreased pain perception, patients
may not be able to report discomfort from
extrinsic factors. On the other hand, with
decreased cellular inflammation, clinicians may not be able to identify evidence
of pressure damage, such as redness, heat
and inflammation. Steroids have also
been reported to be a cause of avascular
necrosis (Williams & Wilkins, 1998), as a
result; patients on steroids are at risk of
developing pressure sores due to poor
tissue perfusion.
Research has shown that some patients
diagnosed with leg ulcers, are likely to
have low mood and become socially
isolated as a result of reduced mobility
and pain (Waishe, 1995; Briggs & Flemming, 2007). This may increase the risk of
this group of patients spending most of
their time chair bound or not too keen on
engaging in physical activities (Roth,
2000) and as a result will increase their
risk of pressure sore development. The
Wateriow scale should consider the
patient's mental state as part of its assessment, of course it does consider the
neurological function of an individual,
but these two are separate entities. Omission of mental healthy assessment
highlights an inadequacy in weighting of
emotional or mental health issues.

Suggestions for practice

development
NICE (2005) suggested that in clinical
practice, practitioners should mobilise
patients including those who are bed and
chair bound by turning them regularly.
As highlighted earlier, mobility reduces
patients' risk of developing pressure

[ournal of Community Nursing May 2010, volume 24, issue 3

WOUND MANAGEMENT
.sores significantly. Practitioners should teach both, formal and
informal carers to consider passive movements for those
patients with comprt>mised mobility or regular repositioning
of those patients who are bedbound.
As highlighted by the Waterlow assessment tool, patient
nutrition is equally important towards the maintenance of a
healthy skin integrity which lowers the risk of developing pressure sores. Therefore, nurses should encourage patients with
skin damage to snack on protein based foods to help boost their
levels of energy and protein replacement. Referrals to the
dietetics con be an effective plan, to educate patients and the
team on the nutritious foods that individuals 'lif risk' can eat.
This could also mean that general practitioners may have to
prescribe nutritional supplements. As a result of using the
Waterlow assessment tool patient's risk of developing pressure
sores will become significantly reduced.
Studies have shown that comprehensive research needs to be
carried out in order to get a better understanding of the actual
factors which contribute to the development of pressure ulcers
(Edwards, 1996; Halfens et al., 2000). However, it has been
demonstrated that the application of the Wateriow assessment
tool reduces the risk of pressure sore development. The
Waterlow assessment tool must be used in conjunction with
other patient assessment tools to aid clinical assessment, so that
clinical resources will be efficiently allocated which will facilitate high quality care and patient treatment {Department of
Health (DH), 2001).
Clinicians must become innovative and proactive rather
than reactive in the way patient care is delivered. For example,
the Waterlow assessment tool was published in 1985, and
revised in 2005 {Table I). Fiowever, in some clinical areas,
patients are still being assessed using the old Waterlow assessment form. On the other hand, clinical practitioners may need
to be educated on how to use the Waterlow assessment tool. As
.1 result of using the Waterlow tool, the government's objective
of having older people being cared for and treated at home will
be achieved as a means of preventing unnecessary hospital
admissions with preventable pressure sores or reduced
hospital stay (DH, 2001).
The Waterlow assessment tool remains a guide to holistic
patient assessment and is necessary when assessing patient's
likelihood of developing pressure sores. However, pressure
area risk is all around our patients from the bed linen they
use to the mattresses and chairs they seat in. Therefore, practitioners have to remain proactive and alert in order to reduce
the patient's risk of developing pressure sores. The risk of
Trust litigation is increasing daily given the current social and
economic systems that our patients live in. However, the decision on pressure relieving equipment to be prescribed by a
practitioner should be governed by the patient's risk of developing pressure sores and the clinician's clinical judgment, not
just a numerical figure from an assessment tool.
Conclusion
Even though, there are other various pressure area assessment
tools in use, the Waterlow scale assessment tool remains the
most commonly used too!. It also acknowledges the cause of
pressure sores as multi-factorial in nature; therefore, they
require a holistic assessment to effectively facilitate patient
centred care. A completed Waterlow tool can effectively highlight areas of patient care which need extra input from members
of the multidisciplinary team in order to reduce risk factors to
developing pressure sores. However, this alone does not stop
patients from developing pressure sores.
[ournal of Community Nursing May 2010, voiume 24, issue 3

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WOUND MANAGEMENT

Reference
Andersen, K. E., Jerisen, O., Kroming, S. A.,
Bouch, E. (1982) "Prevention of pressure
sores by identifying patients at risk". British
Medical journalist: 1370.
Anthony, O., Reynolds, L, Russell, L. (2003)
"A regression analysis of the Waterlow
score in pressure ulcer risk assessment".
Clinical Rehabilitation, 17;2:216-223.
Ash, D. (2002) "An exploration of the occurrence of pressure ulcers in a British spinal
injuries unit". Joumal of Clinical Nursing, 11
;4: 470-478.
Bale, S. Finlay, I., Harding, K. G. (1995)
"Pressure sore prevention in a hospice".
Journal of Wound Care, 4:465-8.
Balzer, K., Pohl, C , Dassen, T., Halfens, R.
(2007) "The Norton, Waterlow, Braden and
care dependency scales: comparing their
validity when identifying patients' pressure sore risk", journal of Wound Ostomy
Continence Nurse, 34 ;4:389-398.
Bamett, M. (2009) "Improving nursing
management of COPD patients", journal of
Community Nursing, 23 ;3:32-38.
Beidon, P., Fletcher, J., Maylor, M.,
Timmons, J. (2009) "What impact will Lord
Darzi's report, 'High Quality Care for All',
have on tissue viability?" Wounds UK, 5;2;
100-106.
Bendavid, R., Abrahamson, J., Arregui, M.
E. (2001) Abdotninal ivall hernias: Principles
and management. London: Springer.
Berlowitz, D. R., Wilking, S. V. B. (1989)
"Risk factors for pressure sores: a comparison of cross-sectional and cohort-derived
data". Journal of American Geriatric Society,
37:1043-1050.
Bridel, J. (1993) "Assessing the risk of pressure sores". Nursiiig Standard, 7;25: 32-35.
Briggs, M., Fiemming, K. (2007) "Living
with leg ulcration: A synthesis of qualitative research". Journal of Advanced Nursing,
59;4: 319-328.
Cox, J. S. (1984) "Current cencepts in the
role of steroids in the treatment of sprains
and strain". Medicine and Science in Sports
and Exercise, 16 ;3:216-218.
Defloor, T., Grypdanck, M. (2005) "Pressure
ulcers: validation of two risk assessment
scales". journal of Clinical Nursing, 4 -,3:373382.
Department of Health. (2001) National
service framework for older people. Available
from http://www.dh.gov.uk/en/PubIicationsand statistics / Publica tions / Publ icatio
nsPolicyAndGuidance/DH^4003066
accessed 02/10/2009.
Dreyfus, H. L., Dreyfus, S. E. (1986) Mind
over machine. New York: The Eree Press.
Edwards, M. (1996) "Pressure sore calculators: some methodological issues". Journal
of Clinical Nursing, 5:307-312.
Finestone, H. M., Levine, S. P., Carlson, G.
A., Chizinsky, K. A., Kett, R. L. (1991)
"Erythema and skin temperature following
continuous sitting in spinal cord injured
individuals". Journal of Rehabilitation
Research and Development, 28: 27-32.
Halfens, R. J., Van Achterberg, T., Bal, R. M.
32

(2000) "Validity and the influence of Braden

scale and the influence of other risk factors;
a multicentre prospective study". International journal of Nursing Studies, 37 ;4:
313-319.

incidents and causes". The Joumal ofTrauma.

Injury, Infection and Critical Care, 42;2: 276278.

Hampton, S. (2005) "Death by pressure

ulcer: being held to account when ulcers
develop", journal of Community Nursing, 19
(7): 26-29.

Pancorbo-Hidalgo,
P.
L.,
GarciaFernandez, F. P., Lopez-Medina, 1. M.,
Alvarez-Nieto, C. (2006) "Risk assessment
scales for pressure ulcer prevention: a
systematic review". Journal of Advanced
, 54 ;1: 94-110.

Hartgrink, H., Wille, J., Knig, T., Hermans,

J., Breslau, P. (1998) "Pressure sores and
tube feeding in patients with a fracture of
the hip: a randomised clinical trial". Clinical
Nutrition, 17:6:287-292.

Papanikolaou, P., Clark, M., Lyne, P. A.

(2002) "Improving the accuracy of pressure
ulcer risk calculators: some preliminary
evidence". International Journal of Nursing
Studies. 39 ;2:\S7-19i.

Hibbs, P. (1985) "The economics of pressure

ulcer prevention". Decubitus, 1 ;3:32-39.
Hillan, E.M. (1999) The problem of pressure
sores. Nursing and Midwifery School:
University of Glasgow.

Parkinson, W. (2004) "Multi-disciplinary

person-centred care: has government
policy helped or hindered?" Nursing Older
People, 16 ;7:U-\7.

Houwing, R. H., Rozendaal, M., WoutersWesseling, W., Beulens, E., Haalboom, J. R.

(2003) "Arandomised, double-blind assessment of the effect of nutritional
supplementation on the prevention of pressure ulcers in hip-fracture patients". Clinical
N l , 22 ;4: 401-405.
Kelly, J. (2005) "Inter-rate reliability and
Waterlow's pressure ulcer risk assessment
tool". Nursing Standard, 19;32:86-93.
Kranse, J. S., Vines, C. L., Farley, T. L.
Sniezek, J., Coker, ]. (2001) "An
exploratory study of pressure ulcers after
spinal cord injury: Relationship to protective behaviors and risk factors". Archives of
Physical Medicine and Rehabilitation, 82 ,1:
107-113.
Levine, J. M., Simpson, M., McDonald, R. J.
(1989) "Pressure sores: a plan for primary
care prevention". Geriatrics, 44:75-90.
Low, A. W. (1990) "Prevention of pressure
sores in patients with cancer". Oncology
Nursing Forum, 17:179-184.
McCormack, B. (2003) "A conceptual
framework for person-centred practice
with older people". International Journal of
Nursing Practice, 9 ;3: 202- 209.
Medline Plus. (2009) Medical dictionary.
Available from: http://www2.merriamwebster.com/cgi-bin/mwmednlm?book=
Medical&va=cachexia accessed on the
29/09/2009.
Moore, Z., Price, P (2004) "Nurses attitudes,
behaviours and perceived barriers towards
pressure ulcer prevention", joumal of Clinical Nursing, 13 ;8:942-951.
National Institute for Health and Clinical
Excellence, (2005) Quick reference guide: The
prevention and treatment of pressure ulcers.
London: NICE.
National Institute for Health and Clinical
Excellence, (2006) Nutritional support for
adults. Oral nutrition support, eternal tube
feeding and parenteral nutrition methods,
evidence and guidance. London: NICE.
Nicholls, C. (2004) "Providing nutritional
information to people with lung disease".
Nursing Times, 100 ;6: 60-61.
O'sullivan, K. L., Engrav, L. H., Maier, R. V,
PUcher, S. L., Isik, F. E, Copass, M. K. (1997)
"Pressure sores in the acute trauma patient:

Rapp, S. M. (2009) "Diabetes, Vascular

disease increase amputation risk after ORIF
for ankle fracture". Orthopedics Today, 29 ;49:
35.
Roth, T. (2000) "Diagnosis and management of insomnia". Clinical Cornerstone, 2-,5:
28-35.
Thompson, D. (2005) "An evaluation of the
Waterlow pressure ulcer risk -assessment
tool". British journal of Nursing, 14 ;88: 455459.
Versluysen, M. (1986) "How elderly
patients with femoral fractures develop
pressure sores in hospital". British Medical
journal 292;6531; 1311-1313.
Vohra, R. K., McColIum, C.N. (1994)
"Education and debate, fortnightly review:
pressure sores". British Medical Journal, 309:
853-857.
Walshe, C. (1995) "Living with a venous leg
ulcer: A descriptive study of patient's experiences". Journal of Advanced Nursing, 22;6:
92-100.
Waterlow, J. A. (1985) "Pressure sores: a risk
assessment card". Nursing Times, 81 ;48:4955.
Waterlow, J. A. (1988) "The Waterlow card
for the prevention and management of
pressure sores: towards a pocket policy".
Care Science and Practice, 6 ;!: S-12.
Waterlow, J. A. (1995) "Reliability of the
Waterlow score". Joumal of Wound Care, 4:
474-475.
Waterlow, J. A. (1997) "Pressure sore risk
assessment in children". Paediatric Nursing,
9;6: 21-24.
Waterlow, J. A. (1998) "Pressure sores in
children: risk assessment". Paediatric
Nursing, 10 ;4: 22-23.
White, R., Cutting, K. F. (2006) Modern
exdate management: a review of wound
treatments. Available from: http: / / wwwworldwidewounds .com / 2006 /
September / White / Modern-Exuda te-Mgt
.html accessed 15/09/09.
Williams & Wilkins (1998) "Stemids cause
of mood disturbances". The Black Letter.
13;4:44.
Worley, C. A. (2007) "Skin failure: the
permissible pressure ulcer?" Dermatology
Nursing, 19 ;4:384-385.

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