• Used to assess the risk for pressure ulcer development.
  • Created to provide better sensitivity and specificity than the Norton by increasing the number of items used.
  • Every patient is evaluated on 8 items:
    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 (disorders associated with tissue malnutrition, neurological deficits, medication, recent surgery or trauma)

Clinical Considerations

  • The Waterlow scale is quick and easy to use screen that provides predictive information about the risk of developing a pressure sore.
  • The scale omits items previously found to be important predictors of pressure ulcer development for people with SCI in acute and rehabilitation settings.
  • The reliability of the scale has not been demonstrated with a SCI population, but poor inter-rater reliability has been reported in other populations.
  • The scale is easy to score and administrate with no patient burden.

ICF Domain

Body Function ▶ Functions of the Skin


  • Clinician-administered; raters indicate client status based on personal knowledge of the client or chart review.
  • Items are scored as either dichotomous (yes/no) or on domain specific scales that range from 0-1 to 3-5.
  • Domains are scored based on descriptive criteria provided on the scoring sheet (for example, ‘body build’: average – 0; above average – 1; obese – 2; below average – 3).
  • Administration time is usually 5-10 minutes.

Number of Items

8 items




  • Scores are totaled to produce a summary score from 3 (best prognosis) to 45 (worst prognosis).
  • Interpreting scores is difficult given lack of detail in item descriptions.
  • Scores of 10+ denote risk of developing a pressure ulcer, 15+ high risk and 20+ very high risk (no rationale is provided for how these numbers were determined.)



Training Required

No formal training required. However reading the manual is recommended.


Can be found here.

# of studies reporting psychometric properties: 2


MCID: not established in SCI
SEM: not established in SCI
MDC: not established in SCI

  • Interpreting scores is difficult given lack of detail in item descriptions.
  • Scores of 10+ denote risk of developing a pressure ulcer, 15+ high risk and 20+ very high risk. No rationale is provided for how these numbers were determined.
  • No normative data or cut-points have been established for the SCI population
  • Published data for the SCI population is available for comparison (see the Interpretability section of the Study Details sheet).


No values were reported for the reliability of the Waterlow scale for the SCI population.


  • Moderate correlation with Norton Scale: r = -0.50 ~ -0.56

(Wellard, 2000)

  • Moderate ROC Analysis: Area under curve = 0.76

(Ash 2002)


No values were reported for the responsiveness of the Waterlow Scale for the SCI population at this time.

Floor/Ceiling Effect

64% of patients were reported to be high risk, while the remaining 36% of patients were reported to be at very high risk.

(Wellard, 2000)


Dr. William Miller, Kyle Diab, Emily Procter, Gita Manhas

Date Last Updated

22 July 2020

Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. J Clin Nurs 2002;11:470-478.

Kelly J. Inter-rater reliability and Waterlow’s pressure ulcer risk assessment tool. Nursing Standard 2005;19:86-87,90-92.

Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds 1999;11:45-57.

Salzberg C A, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. Am J Phys Med Rehabil 1996;75:96-104.

Waterlow JJ. Pressure sores: a risk assessment card. Nurs Times1985;81:49-55.

Wellard S, Lo SK. Comparing Norton, Braden and Waterlow risk assessment scales for pressure ulcers in spinal cord injuries. Contemp Nurse 2000;9:155-160.