On admission to the ward all stroke patients should be routinely assessed to determine whether they have developed or are at risk of developing pressure ulcers. Those found to be at risk should have on-going monitoring. The Waterlow Scale is one of many clinical scoring systems developed to indicate an individual patient’s risk.
The nurse on the stroke unit has calculated Mrs McGinty’s score using the Waterlow Scale below:
Mrs McGinty is 84 years old. Her daughter has reported that she has been eating poorly since her previous stroke and that she has lost approximately 7.5kg in weight resulting in a BMI score of 17.2. On admission to the stroke unit she had a partial thickness skin break on her sacrum. She is continent but has restricted mobility due a right sided hemiplegia.
Scottish Adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Classification Tool: Grading Tool
Page last reviewed: 20 Apr 2021
