JCN WOUND MANAGEMENTEdwin Tapiwa Chamangadiscusses the use of tiieWateriow assessment tool inwound management

Key words:Wateriow assessment toolf-folistic assessmentPressure sore prevention

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

Edwin Tapiwa Chamanga RGN, BSc(Hons), (BSc Hons) Specialist CommunityPractice (District Nursing), currently readingfor an MSc Skin integrity skills andtreatments is a Tissue Viability NurseSpecialist, City and Hackney Primary CareTrust, London

ArUcfe accepted for publication: September 2009

A critical review of theWateriow toolThe Wateriow assessment toolremains the most commonly usedtool for assessing a patient's risk ofdeveloping pressure sores. According toa random statistical survey conducted oneight primary care trusts (PCTs) withinthe north and east London region itemerged that six PCTs used the Wateriowscale assessment tool. These PCTs are notexclusive and throughout the UK thereare more organisations using theWateriow scale assessment tool.Wateriow (1985) and Hibbs (1985) statethat around 95 per cent of pressure soresare preventable particularly with theprovision of sophisticated pressure soreprevention equipment (Beldon et al,2009). However, this is not the case inclinical practice as incidents of pressureulcers are continuously being reported.

Pressure ulcer development as a resultof poor patient assessment and equip-ment acquisition remains on the increase(Moore & Price, 2004; Hampton, 2005).As a result of increased collaborationbetween secondary care trusts and PCTs,patients are now being discharged intothe community requiring pressure areacare and equipment ordering beforegoing home. This transition is facilitatedby the use of a similar pressure sore riskassessment tools between thedischarging hospital and the community.This article aims to review the Wateriowscale assessment tool as an effectivemeasure of a patient's predisposingfactors (risk) to pressure sore develop-ment, and as a guide to effective pressureequipment ordering.

The Wateriow tootThe Wateriow scale assessment tool wasintroduced into practice in 1985(Wateriow, 1985). More than two decadeson, it remains the most popularly usedpressure area assessment tool in manyhospitals and PCTs across the country(Ash, 2002; Defloor & Grypdonck, 2005).The tool enables patients to be assessedaccording to each individual's risk ofdeveloping pressure sores (Pancorbo-Hidalgo et al, 2006). It explores thefollowing risk factors: weight for heightratio, continence, skin condition,mobility, sex and age, nutrition, skincondition, neurological function, majorsurgery or trauma and lastly the type of

medication the patient will be taking.Assessing these risk factors for each indi-vidual enables practitioners to offer anddeliver person centred care, which istailored for individual health care needs(McCormack, 2003; Parkinson, 2004)(Table 1).

Discussion and criticalevaluationsWateriow effectively viewed the devel-opment of pressure sores as beinginfluenced by both extrinsic and intrinsicfactors (Wateriow, 1995; Balzer et ai,2007). The intrinsic factors include age,malnutrition, dehydration, incontinence,pre-existing medical cond itions andcertain types of medication. Whereas theextrinsic factors are considered to bepressure, shearing and friction whichdirectly affect skin integrity. Wateriow(1997; 1998) argued that nursing inter-ventions can effectively alleviateextrinsic factors, yet in reality most of theabove mentioned intrinsic factors can bealleviated by nursing interventions suchas multidisciplinary team working apartfrom patient's age and medical condi-tion. Comversely, Balzer ct al. (2007)criticised Waterlow's idea of consideringextrinsic factors as probable causes ofpressure sores, when there are notconsidered or mentioned on her assess-ment form (Table 1 ). There is also a lack ofassessment guidelines or descriptor onthe tool which is a major cri ticsm(Bridel,1993). As a result, it is difficult to use fornovice clinicians as will be discussed insubsequent paragraphs.

Build/ Weight for HeightWateriow assessment tool highlights theimportance of assessing body build inrelation to patient's risk of developing apressure sores. This is important as partof a patient's total holistic assessmentas it aids patient centred care and theprovision of cost effective pressurerelieving equipment. For all patientspresenting with a body mass index (BMl)greater than 20 they must have a nutri-tional assessment screening (NationalInstitute for Health and Clinical Excel-lence (NICE), 2006), this can aid pressuresore prevention by providing necessarypressure relieving equipment. From theabove it is evident that the Wateriow

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WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICYRING SCORES IN TABLE, ADD TOTAL. MORE THAN 1 SCORE/CATEGORY CAN BE USED

BUILD/WEIGHTFOR HEIGHT

AVERAGEBMi = 20-24.9ABOVE AVERAGEBMi = 25-29.9OBESEBMi > 30BELOW AVERAGEBMI < 20

CONTINENCECOMPLETE/CATHETERISEDURiNE INCONTFAECAL INCONTURINARY + FAECALINCONTiNENCE

0

1

2

3

012

3

SCORE

10+AT RISK

15+ HIGH RISK20+VERY HIGH RISK

SKIN TYPEVISUAL RISK

AREASHEALTHYTiSSUE PAPERDRYOEDEMATOUSCLAMMY, PYREXiADISCOLOUREDGRADE 1BROKEN/SPOTSGRADE 2-4

MOBILITYFULLYRESTLESS/FIDGETYAPATHETiCRESTRICTEDBEDBOUNDe.g. TRACTIONCHAIRBOUNDe.g. WHEELCHAiR

01111

2

3

0123

4

5

SEXAGE

MALEFEMALE14-4950-6465-7475-8081 +

1

2

1

2

3

4

5

MALNUTRITION SCREENING TOOL (MST)(Nutrition Vof.15. No.6 1999 - Australia

A- HAS PATiENT LOSTWEIGHT RECENTLYYES GO TO BNO - GO TO CUNSURE -GO TOC

ANDSCORE 2

B - WEiGHT LOSS SCORE0.5 - 5kg = 1

5-10kg = 210-15kg = 3

>15kg = 4unsure = 2

C - PATiENT EATING POORLYOR LACK OF APPETITE'NO' = 0; 'YES'SCORE = 1

NUTRITiON SCOREif > 2 refer for nutrition

assessment / intervention

SPECIAL RISKSTISSUE MALNUTRITIONTERMINAL CACHEXiAMULTiPLE ORGAN FAILURESiNGLE ORGAN FAILURE(RESP, RENAL. CARDIAC,}PERIPHERAL VASCULARDISEASEANAEMIA (Hb 2 HR#ON TABLE > 6 HR#

4-64-64-6

A558

MEDICATION - CYTOTOXICS, LONG TERM/HIGH DOSE STEROIDS.ANTI-INFLAMMATORY MAX OF 4

# Scores can be discounted after 48 hours provided patient is recovering normaiiyIS 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 alonescreerng tool as it compliments othernursing assessment tools. Hence theincorporation of the MalnutritionScreening Tools (MST) on the assessmentform in Tablel. ,

ContinenceWaterlow assessment tool identifiedcontinence as an aspect that needs to beassessed when screening patients' risk ofdeveloping pressure sores. It has beenreported that skin integrity is compro-mised by maceration as a result of bothurine and faecal matter (Low, 199; Fine-stone et al., 1991). This section of theassessment tool enables clinicians toeffectively assess patients and preventthe development of pressure sores.

Skin TypeWorley (2007) observed that the skin asthe largest organ of the human body, islike any other organ and it is prone tofailure. Therefore, with the ageing anddisease process, human skin condition issubject to change as noted by Waterlow.

She reported that patient's skin type andvisual characteristics are subjected tomulti-factors. Hence, when assessingpatients, nurses are encouraged toconsider all the possible risk factorswhich may predispose them to devel-oping pressure sores. However, thissection of the assessment tool is notspecific on the location of the broken skin,because some patients may have abroken skin which does not affect theirmobility or any other pressure ulcer riskrelated factors. For example, a skin tear offragile skin behind the palm, may havealso been highlighted earlier as part oftissue paper skin, meaning that on thissection a patient will end up with anunnecessarily higher score.

Waterlow (1995) advocates for stafftraining on the use of the tool before it canbe used effectively. However, it iscommon practice for nurses to use thetool without training, therefore it isunsurprising if difficulties arise whennurses fail to make the correct distinc-tions between tissue paper, dry.

oedematous, clammy and pyrexia skin. Itis important to identify the correct skintype during assessment; this will facili-tate the ordering of appropriate pressurerelieving equipment. Due to a lack ofappropriate descriptors of various skintypes, it can be problematic for thissection of the assessment tool to be effec-tively employed in clinical practice.

MobiHtyLow (1990) argues that any mobilityimpairing condition is likely to increasethe development of pressure sores.Waterlow (1988) accords with this idea,hence on the assessment tool the risk ofdeveloping pressure sores increases withevery possible restraint on mobility.Wateriow rated mobility within a rangeof 0 to 5 and gave descriptors such as fullymobile to being chair bound as anincreased risk of developing pressureulcers. This is logical and coherent,however, it would have been helpful ifexamples were included to indicate theterm traction, apathetic and what theterm restricted is referring to.

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Sex/AgeAnthony et al (2003) and Papanikolaou etal. (2002) suggest that gender should beremoved from the tool as it does not signif-icantly predict the risk of pressure soredevelopment. However, in a study byVersluysen (1986) and Bale et al (1995) 327hospice patients were assessed using theNorton scale every 48 hours. Resultsshowed that 21 per cent of womencompared with nine per cent of mendeveloped pressure ulcers. Though this isconsistent with the Waterlow's scale,Anthony et al (1998) found in a compara-tive study of risk scores of 150 wheelchairusers and 9022 hospital inpatients that 45per cent of males developed ulcerscompared with only 22 per cent offemales. More research is needed to clarifythese discrepancies as the reason remainsunclear (Thompson, 2005). Therefore, itleaves the application of this section of theassessment tool questionable.

Evidence suggests that the ageingprocess results in a disruption of collagenfibers (Bendavid et al, 2001). It has alsobeen noted that with the ageing processpeople lose the subcutaneous tissue,reduction in pain perception andreduced cell mediated immunity (Levineet al, 1989). As a result of the ageingprocess the skin became less resilient andregenerative as it was previously, there-fore, it warrants the need for pressuredamage risk assessment.

Malnutrition Screening Tool (MST)It is important that the Watertowscreening tool addresses patient's nutri-tional habits, as evidence suggests thatdehydration, anaemia, electrolyte imbal-ance and malnutrition often lead to thedevelopment of pressure sores (Berlowitz& Wilking, 1989). For instance, patientswith highly exudating ulcers are likely tolose important nutrients through thewound exdate (White & Cutting, 2006)which will result in nutrient deficiency atcellular level. Therefore, this section oftheassessment form is very important as ithighlights the risk factors for patientsdeveloping pressure sores due to a lack ofadequate nutrients.

Special risksTissue malnutritionThis section of the tool is quite selfexplanatory and user friendly, however,the only limitation is the use of the word"terminal cachexia" which may not beeasily understood and defined by clinicalpractitioners, Medline Plus (2009) definescachexia as 'a general physical wasting andmalnutrition usually associated with chronic

disease'. From the above given definitionthe Wateriow scale is repetitive, if apatient is suffering from "terminalcachexia", it would have been identifiedunder the section build or weight forheight section with a body mass indexbelow average. On the other hand, if apatient was suffering from chronicobstructive pulmonary disease (COPD)they would have not been assessed underspecial risks. Yet, evidence and reportssuggests that approximately 30 per centofpatients with COPD lose weight, whilstsome have a tendency of becoming overweight (NichoUs, 2004; Barnett, 2009).

Out of eight colleagues who were askedwhat "terminal cachexia" meant, none ofthem were able to give a valid definition.According to Kelly (2005) this demon-strates that nurses are prepared to ignorethings they do not understand rather thanask for clarification. This could be true formany nurses, and if so it means they mayeither have at one time unnecessarily overscored or underscored a patient whilstusing the assessment tool.

The assessment tools also takes intoconsideration those patients withvascular diseases as noted by Vbhra andMcCollum (1994) and Hillan (1999) thatpatients with arterial disease have agreater risk of developing pressure sores,as a result of compromised local tissueperfusion. With the increase in vasculardiseases (Rapp, 2009) it is imperative thatthis section is also considered on theassessment tool.

Neurological deficitPatients with neurological disorders,such as multiple sclerosis and spinal cordlesions have an 85 per cent chance ofdeveloping pressure sores (Finestone etal, 1991; Kranse et al, 2001). In clinicalpractice it is important to screen thesepatients and reduce their risk of devel-oping pressure sores, by the provision ofappropriate pressure relieving equip-ment. One of the weaknesses of thissection of the assessment form is its lackof clarity on risk scoring; it scores risks onthe range of 4 - 6. This scoring can beconfusing even to experienced clinicians.It is not clear whether one awards a fourif the patient is diagnosed with one of thelisted neurological complications likediabetes or ii^ the patient becomesterminal. It is also not clear as to whatscore would a patient get if they wereboth diabetic and paraplegic.

Major Surgery or TraumaStudies by Andersen ef al (1982) andO'Sullivan et al (1997) reported that

patients who undergo surgery or suffertrauma are at risk of developing pressuresores due to either extended immobilisa-tion or direct tissue damage due totrauma. The above two mentioned factorsare related to reduced dermal perfusion;hence Wateriow assesses them as predis-posing factors of developing pressuresores. However, Wateriow scale does notspecify the length of time to be consideredpost surgery or trauma that can increasethe risk of developing pressure sores.

MedicationIt has been noted that steroids and anti-inflammatory medication reducessynovial inflammation, effusion andpain sensation. As a result this masks theprotective pain mechanism which apatient would experience (Cox, 1984;Williams & Wilkins, 1998), Therefore, it isimportant that Wateriow consideredthese medicines as predisposing factorsfor patients developing pressure sores.With decreased pain perception, patientsmay not be able to report discomfort fromextrinsic factors. On the other hand, withdecreased cellular inflammation, clini-cians may not be able to identify evidenceof pressure damage, such as redness, heatand inflammation. Steroids have alsobeen reported to be a cause of avascularnecrosis (Williams & Wilkins, 1998), as aresult; patients on steroids are at risk ofdeveloping pressure sores due to poortissue perfusion.

Research has shown that some patientsdiagnosed with leg ulcers, are likely tohave low mood and become sociallyisolated as a result of reduced mobilityand pain (Waishe, 1995; Briggs & Flem-ming, 2007). This may increase the risk ofthis group of patients spending most oftheir time chair bound or not too keen onengaging in physical activities (Roth,2000) and as a result will increase theirrisk of pressure sore development. TheWateriow scale should consider thepatient's mental state as part of its assess-ment, of course it does consider theneurological function of an individual,but these two are separate entities. Omis-sion of mental healthy assessmenthighlights an inadequacy in weighting ofemotional or mental health issues.

Suggestions for practicedevelopmentNICE (2005) suggested that in clinicalpractice, practitioners should mobilisepatients including those who are bed andchair bound by turning them regularly.As highlighted earlier, mobility reducespatients' risk of developing pressure

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.sores significantly. Practitioners should teach both, formal andinformal carers to consider passive movements for thosepatients with comprt>mised mobility or regular repositioningof those patients who are bedbound.

As highlighted by the Waterlow assessment tool, patientnutrition is equally important towards the maintenance of ahealthy skin integrity which lowers the risk of developing pres-sure sores. Therefore, nurses should encourage patients withskin damage to snack on protein based foods to help boost theirlevels of energy and protein replacement. Referrals to thedietetics con be an effective plan, to educate patients and theteam on the nutritious foods that individuals 'lif risk' can eat.This could also mean that general practitioners may have toprescribe nutritional supplements. As a result of using theWaterlow assessment tool patient's risk of developing pressuresores will become significantly reduced.

Studies have shown that comprehensive research needs to becarried out in order to get a better understanding of the actualfactors which contribute to the development of pressure ulcers(Edwards, 1996; Halfens et al., 2000). However, it has beendemonstrated that the application of the Wateriow assessmenttool reduces the risk of pressure sore development. TheWaterlow assessment tool must be used in conjunction withother patient assessment tools to aid clinical assessment, so thatclinical resources will be efficiently allocated which will facili-tate high quality care and patient treatment {Department ofHealth (DH), 2001).

Clinicians must become innovative and proactive ratherthan reactive in the way patient care is delivered. For example,the Waterlow assessment tool was published in 1985, andrevised in 2005 {Table I). Fiowever, in some clinical areas,patients are still being assessed using the old Waterlow assess-ment form. On the other hand, clinical practitioners may needto be educated on how to use the Waterlow assessment tool. As.1 result of using the Waterlow tool, the government's objectiveof having older people being cared for and treated at home willbe achieved as a means of preventing unnecessary hospitaladmissions with preventable pressure sores or reducedhospital stay (DH, 2001).

The Waterlow assessment tool remains a guide to holisticpatient assessment and is necessary when assessing patient'slikelihood of developing pressure sores. However, pressurearea risk is all around our patients from the bed linen theyuse to the mattresses and chairs they seat in. Therefore, practi-tioners have to remain proactive and alert in order to reducethe patient's risk of developing pressure sores. The risk ofTrust litigation is increasing daily given the current social andeconomic systems that our patients live in. However, the deci-sion on pressure relieving equipment to be prescribed by apractitioner should be governed by the patient's risk of devel-oping pressure sores and the clinician's clinical judgment, notjust a numerical figure from an assessment tool.

ConclusionEven though, there are other various pressure area assessmenttools in use, the Waterlow scale assessment tool remains themost commonly used too!. It also acknowledges the cause ofpressure sores as multi-factorial in nature; therefore, theyrequire a holistic assessment to effectively facilitate patientcentred care. A completed Waterlow tool can effectively high-light areas of patient care which need extra input from membersof the multidisciplinary team in order to reduce risk factors todeveloping pressure sores. However, this alone does not stoppatients from developing pressure sores.

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

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ReferenceAndersen, K. E., Jerisen, O., Kroming, S. A.,Bouch, E. (1982) "Prevention of pressuresores by identifying patients at risk". BritishMedical journalist: 1370.Anthony, O., Reynolds, L, Russell, L. (2003)"A regression analysis of the Waterlowscore in pressure ulcer risk assessment".Clinical Rehabilitation, 17;2:216-223.Ash, D. (2002) "An exploration of the occur-rence of pressure ulcers in a British spinalinjuries 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 andcare dependency scales: comparing theirvalidity when identifying patients' pres-sure sore risk", journal of Wound OstomyContinence Nurse, 34 ;4:389-398.Bamett, M. (2009) "Improving nursingmanagement of COPD patients", journal ofCommunity Nursing, 23 ;3:32-38.Beidon, P., Fletcher, J., Maylor, M.,Timmons, J. (2009) "What impact will LordDarzi'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: Principlesand management. London: Springer.Berlowitz, D. R., Wilking, S. V. B. (1989)"Risk factors for pressure sores: a compar-ison of cross-sectional and cohort-deriveddata". Journal of American Geriatric Society,37:1043-1050.Bridel, J. (1993) "Assessing the risk of pres-sure sores". Nursiiig Standard, 7;25: 32-35.Briggs, M., Fiemming, K. (2007) "Livingwith leg ulcration: A synthesis of qualita-tive research". Journal of Advanced Nursing,59;4: 319-328.Cox, J. S. (1984) "Current cencepts in therole of steroids in the treatment of sprainsand strain". Medicine and Science in Sportsand Exercise, 16 ;3:216-218.Defloor, T., Grypdanck, M. (2005) "Pressureulcers: validation of two risk assessmentscales". journal of Clinical Nursing, 4 -,3:373-382.Department of Health. (2001) Nationalservice framework for older people. Availablefrom http://www.dh.gov.uk/en/PubIica-tionsand statistics / Publica tions / Publ icationsPol icyAndGuidance/DH^4003066accessed 02/10/2009.Dreyfus, H. L., Dreyfus, S. E. (1986) Mindover machine. New York: The Eree Press.Edwards, M. (1996) "Pressure sore calcula-tors: some methodological issues". Journalof 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 followingcontinuous sitting in spinal cord injuredindividuals". Journal of RehabilitationResearch and Development, 28: 27-32.Halfens, R. J., Van Achterberg, T., Bal, R. M.

(2000) "Validity and the influence of Bradenscale and the influence of other risk factors;a multicentre prospective study". Interna-tional journal of Nursing Studies, 37 ;4:313-319.Hampton, S. (2005) "Death by pressureulcer: being held to account when ulcersdevelop", journal of Community Nursing, 19(7): 26-29.Hartgrink, H., Wille, J., Knig, T., Hermans,J., Breslau, P. (1998) "Pressure sores andtube feeding in patients with a fracture ofthe hip: a randomised clinical trial". ClinicalNutrition, 17:6:287-292.Hibbs, P. (1985) "The economics of pressureulcer prevention". Decubitus, 1 ;3:32-39.Hillan, E.M. (1999) The problem of pressuresores. Nursing and Midwifery School:University of Glasgow.Houwing, R. H., Rozendaal, M., Wouters-Wesseling, W., Beulens, E., Haalboom, J. R.(2003) "Arandomised, double-blind assess-ment of the effect of nutritionalsupplementation on the prevention of pres-sure ulcers in hip-fracture patients". ClinicalN l , 22 ;4: 401-405.

incidents and causes". The Joumal ofTrauma.Injury, Infection and Critical Care, 42;2: 276-278.Pancorbo-Hidalgo, P. L., Garcia-Fernandez, F. P., Lopez-Medina, 1. M.,Alvarez-Nieto, C. (2006) "Risk assessmentscales for pressure ulcer prevention: asystematic review". Journal of Advanced

, 54 ;1: 94-110.

Kelly, J. (2005) "Inter-rate reliability andWaterlow's pressure ulcer risk assessmenttool". Nursing Standard, 19;32:86-93.Kranse, J. S., Vines, C. L., Farley, T. L.Sniezek, J., Coker, ]. (2001) "Anexploratory study of pressure ulcers afterspinal cord injury: Relationship to protec-tive behaviors and risk factors". Archives ofPhysical Medicine and Rehabilitation, 82 ,1:107-113.Levine, J. M., Simpson, M., McDonald, R. J.(1989) "Pressure sores: a plan for primarycare prevention". Geriatrics, 44:75-90.Low, A. W. (1990) "Prevention of pressuresores in patients with cancer". OncologyNursing Forum, 17:179-184.McCormack, B. (2003) "A conceptualframework for person-centred practicewith older people". International Journal ofNursing Practice, 9 ;3: 202- 209.Medline Plus. (2009) Medical dictionary.Available from: http://www2.merriam-webster.com/cgi-bin/mwmednlm?book=Medical&va=cachexia accessed on the29/09/2009.Moore, Z., Price, P (2004) "Nurses attitudes,behaviours and perceived barriers towardspressure ulcer prevention", joumal of Clin-ical Nursing, 13 ;8:942-951.National Institute for Health and ClinicalExcellence, (2005) Quick reference guide: Theprevention and treatment of pressure ulcers.London: NICE.National Institute for Health and ClinicalExcellence, (2006) Nutritional support foradults. Oral nutrition support, eternal tubefeeding and parenteral nutrition methods,evidence and guidance. London: NICE.Nicholls, C. (2004) "Providing nutritionalinformation 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:

Papanikolaou, P., Clark, M., Lyne, P. A.(2002) "Improving the accuracy of pressureulcer risk calculators: some preliminaryevidence". International Journal of NursingStudies. 39 ;2:\S7-19i.Parkinson, W. (2004) "Multi-disciplinaryperson-centred care: has governmentpolicy helped or hindered?" Nursing OlderPeople, 16 ;7:U-\7.Rapp, S. M. (2009) "Diabetes, Vasculardisease increase amputation risk after ORIFfor ankle fracture". Orthopedics Today, 29 ;49:35.Roth, T. (2000) "Diagnosis and manage-ment of insomnia". Clinical Cornerstone, 2-,5:28-35.Thompson, D. (2005) "An evaluation of theWaterlow pressure ulcer risk -assessmenttool". British journal of Nursing, 14 ;88: 455-459.Versluysen, M. (1986) "How elderlypatients with femoral fractures developpressure sores in hospital". British Medicaljournal 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 legulcer: A descriptive study of patient's expe-riences". Journal of Advanced Nursing, 22;6:92-100.Waterlow, J. A. (1985) "Pressure sores: a riskassessment card". Nursing Times, 81 ;48:49-55.Waterlow, J. A. (1988) "The Waterlow cardfor the prevention and management ofpressure sores: towards a pocket policy".Care Science and Practice, 6 ;!: S-12.Waterlow, J. A. (1995) "Reliability of theWaterlow score". Joumal of Wound Care, 4:474-475.Waterlow, J. A. (1997) "Pressure sore riskassessment in children". Paediatric Nursing,9;6: 21-24.Waterlow, J. A. (1998) "Pressure sores inchildren: risk assessment". PaediatricNursing, 10 ;4: 22-23.White, R., Cutting, K. F. (2006) Modernexdate management: a review of woundtreatments. Available from: http: / / www-worldwidewounds .com / 2006 /September / White / Modern-Exuda te-Mgt.html accessed 15/09/09.Williams & Wilkins (1998) "Stemids causeof mood disturbances". The Black Letter.13;4:44.Worley, C. A. (2007) "Skin failure: thepermissible pressure ulcer?" DermatologyNursing, 19 ;4:384-385.

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