The attention will now shift to one of the individual aspects that make up the initial assessment. The Waterlow assessment was created by Judy Waterlow (1985), it is a tool created to assist health practitioners to assess whether a patient is at risk of developing pressure ulcers, it is by far the most frequently used assessment tool in the UK (Judy-waterlow.co.uk 2007). The Waterlow is applicable to Mr Adams due to his immobility status, as stated by Lareau and Sawyer (2010) if a patient is restricted to bed rest as part of the management for a hip fracture they are at higher risk of further complications due to immobilisation, these complications include pressure sores. The Waterlow assessment tool comprises of two parts, the first is a scoring system with a guide to a patient’s risk status based on the level they score, the three status’s are ‘at risk’, ‘high risk’ and ‘very high risk’. The second part is a guide for the nursing care required according to the patient’s status.
It also has guidelines to wound classification, providing a description of the different grades of ulcer. The scoring system consists of areas that are all deemed to be factors that may contribute towards a patient’s risk of developing pressure ulcers. These include a patient’s build, tissue viability, sex, nutritional status, continence, mobility and other special risks such as co-morbidities and medications. The theory is, the higher the patient scores within each area and overall the higher the patient is at risk of obtaining pressure ulcers (Judy-waterlow.co.uk 2007). The tool’s ease of use meant assessing Mr Adams’s Waterlow score was straightforward; however as Judy (1985) states due to its simplicity professional judgement should also be used to determine a patient risk status. This includes extrinsic factors that are not listed in the tool, for example the length of time an individual stays in one position for and whether or not they are able to reposition themselves and recognise when they need to do so (Guy 2007).
This is particularly relevant to Mr Adams’s for although he has been restricted to bed rest he is still capable of repositioning himself on a regular basis and therefore reducing his risk of pressure ulcers. The majority of the information needed to conduct the assessment was obtained through asking questions and referring to medical notes, however in order to fully assess Mr Adams’s tissue viability a physical examination needed to take place, this involved obtaining consent to assess Mr Adams’s skin especially around pressure areas such as the sacrum, heels, elbows and shoulders as suggested by the NICE (2005). In order to maintain Mr Adams’s privacy and dignity the curtains were drawn around the patient throughout the whole assessment. Another aspect to the assessment tool required Mr Adams’s to be weighed in order to obtain his BMI, due to his fractured hip this was not possible, therefore an estimate had to be made; this may affect the reliability of the overall score.
Both Franks et al (2003) and Nixon and McGough (2001) have challenged the validity of tools such as the Waterlow assessment suggesting that they can either over predict the risk causing unnecessary costs with preventative equipment that is not needed or under predict a patients risk causing a patient to develop pressure ulcers that should have been prevented. This lack of validity could be due to the reliability being placed on the clinical judgement of the health professional conducting the assessment to accurately report findings (Kelly 2005), for example by not properly assessing a patients tissue viability or by not asking about a patients past history of pressure ulcers may could lead to a under predicted risk score.
On the other hand, in Mr Adams’s case by not assessing that although he is bedbound he is capable of repositioning may lead to an over predicted risk score. Reliability is also affected by responses given by the patient, for example a patient maybe embarrassed to express continence issues (NHS 2010) and give false answers. Guy (2007) sums up the effectiveness of tools such as the Waterlow well by stating that assessing a patient’s risk of obtaining a pressure ulcer requires multifactorial consideration, therefore a risk assessment tool should only assist in signposting toward possible risk factors and should not be used as the only means to assess risk, clinical judgement must play a key role in initiating appropriate care plans.