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Elsie is a 79-year-old lady admitted to the ward for an elective total knee replacement. A total knee replacement is a surgical procedure, which replaces damaged or injured parts of the knee joint with artificial parts. To perform this procedure, the muscles and ligaments that surround the knee are separated in order to remove cartilage and bone from the ends of the thigh bone (femur) and the shin bone (tibia). It may also be necessary to remove part of the kneecap (patella).

The implant is then cemented into place. Total knee replacements are usually performed on people suffering with severe arthritic conditions. A patient would normally be deemed suitable for the procedure if found to be suffering from daily pain, significant stiffness, instability or deformity of the knee, or if suffering from severe pain which restricts the patients normal daily activities. Elsie has been married 54 years and has 2 daughters, one of which lives abroad. Elsie and her husband live in a bungalow with an average sized garden. Of late Elsie has been unable to participate in one of her favourite pastimes due to the stiffness and pain in her knee.

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Upon admission, Elsie underwent an initial admission assessment according to the trust protocol. This assessment, based around the Activities of Living, also incorporated screening tools such as the Waterlow Scale used to assess the risk of pressure sores to a patient and to aid the prevention of them. It also includes a Moving and Handling risk assessment to assess the clients level of dependence or independence along with their mobility status. A Nutritional-screening tool is also used to assess the patient’s nutritional status and to identify any needs relating to it.

This essay will focus on the Waterlow scale in particular along with any risks identified as a result of its use for the patient. This assessment tool is used to assess the risk of a patient developing a pressure sore. Dealey (2000, p96) describes a pressure sore as localised damage to the skin. This damage is caused by the blood supply to the area being disrupted and is usually caused by extrinsic factors such as pressure or shearing forces on the skin.

There are also a number of internal factors that determine whether or not a patient will develop pressure damage such as their age, reduced mobility, compromised nutritional status, body weight, incontinence and poor blood supply. The result of pressure sore occurrence can mean a delayed stay in hospital, increased pain and distress to the patient and increased costs to the National Health Service.

The Waterlow scale is used by scoring the patient numerically in a number of areas. The areas covered are build and weight according to a persons height, continence, skin type, mobility, sex, age and appetite. It also scores on a range of special risk areas such as tissue malnutrition, neurological deficit, major surgery or trauma and certain medications such as cytotoxic drugs. The score is then added up and the perceived risk to the patient is identified. A client with a score of 10+ is deemed at low risk of developing pressure damage. A score of 13+ suggests that the client is at high risk while a score of 20+ suggests that the patient is at a very high risk of developing a pressure sore. For any client identified as being at risk of developing a pressure sore, a treatment plan must be agreed upon and implemented.

There is a range of pressure relieving equipment available to aid in the prevention of pressure damage such as pressure relieving mattresses and cushions. However, these alone are not fully effective. A patient must still be encouraged or assisted to change position frequently, their nutrition status should be monitored and clients must avoid shearing forces on their skin which may cause damage.

Elsie’s assessment identified her as being at risk of developing a pressure ulcer with a score of 11. Waterlow (1998) cited by Mallett and Dougherty (2003, p694), recommends that a score of 10+ does not require the use of pressure relieving devices but instead requires careful monitoring of the patient and measures such as ensuring frequent position changes. The aim with Elsie was to achieve mobilisation as soon as possible.

However, monitoring and pressure care prevention would be vital in the immediate post-operative period as Elsie would be immobile. As previously mentioned, according to the Trust protocol Elsie’s admission to the ward included a pressure ulcer risk assessment according to the Waterlow scale. The Waterlow scale is just one of a number of pressure ulcer risk assessment tools available, but is one of the most widely used.

The majority of the information gathered as part of this assessment is taken from the nurses own observations but should also be collated as part of a discussion between both the nurse and the patient. In Elsie’s case re-evaluations of the risk assessments were not routinely carried out. Pressure area prevention and care were carried out however, the risk assessment was not recalculated therefore, the documentation was not completed accurately.

The process does not end after the care plan has been formulated following the completion of the first risk assessment. As Elsie’s mobility would be impaired immediately post-operatively it could be anticipated that her risk of developing a pressure sore would also increase. This is due to factors such as mobility restriction due to post-operative pain and reduced appetite. Another contributing factor is the actual surgery itself.

It is recommended that the patient should actually be reassessed at each point that their condition and mobility changes in order to formulate accurate and appropriate care plans and treatment as recognised by Hilton and Athorn (2004, p23) and the National Institute for Clinical Excellence (2001). Risk assessments must be completed and acted upon to prevent them from becoming useless exercises.

As well as identifying actual or potential risks and reducing accidents and ill health, properly completed risk assessments also serve to protect the professionals using them. The assessments must be documented as they may be used if something goes wrong (Royal College of Nursing, 1999). In today’s litigation society this is more important than ever as each nurse is accountable for their own decision-making along with the care they provide.

In Elsie’s case, a care plan was formulated from the results of her assessments that included factors such as assessing her skin daily, ensuring satisfactory dietary intake and hydration levels, educating and encouraging Elsie to relieve her own pressure by mobilising as much as possible. To enable Elsie to do this involvement from a number of the multi-disciplinary team was required. Each day various healthcare assistants, student nurses and staff nurses from the ward assisted Elsie in checking her skin integrity by assisting with washing and moisturising. Doctors and pharmacists also provided care; in particular, post-operative pain control is an important factor to address when facilitating a patient’s mobilisation. If a patient is in a lot of pain it is going to prove more difficult for them to mobilise.

Elsie was also seen by a physiotherapist who provided her with a walking frame and a range of exercises to aid her rehabilitation. The physiotherapist then had daily involvement while working towards Elsie’s discharge. Prior to discharge, Elsie had a check x-ray to ensure that everything was as it should be from an orthopaedic perspective as well as participating in an activities of living assessment to assess whether she would benefit from the provision and installation of any equipment at her home.

Social circumstances must be taken in to account and assessed in order to establish whether any further help is required. As Elsie lived with her husband who was able to assist with cooking and cleaning and a daughter that would also be able to help out, she was able to return home without the need for any further social input such as carers. As a result of the care she received, Elsie did not develop a pressure sore and so was discharged home without suffering any delays.

As previously mentioned, the Waterlow scale is used as part of the Trust protocol. However, other assessment tools routinely used to assess the risk of developing a pressure ulcer include the Norton scale and the Braden scale. There has been much discussion and many studies carried out in an attempt to evaluate the efficacy of the differing risk assessment scales. A study conducted by Smith (1989) and cited by Mallett and Dougherty (2003, p693) concluded that the Waterlow scale was the most effective at predicting the risk of developing pressure sores. In contrast to this, studies carried out by Pang and Wong (1998, p153) and Stevenson (2004, p81) found the Braden scale to be the most accurate risk assessment.

A more recent study conducted by Defloor and Grypdonck (2004) concluded that the pressure sore risk assessment tools currently available are only of limited value. As a result of this many patients may be falsely identified as being at risk or not at risk. It appears that the efficacy of the tool is relative to the users own experience of the tool. Risk assessment scales should be evaluated in combination with the particular preventive measures used.

The main criticism of the care planning relating to Elsie was the lack of formal reassessment. Whilst the staff provided a good level of care, the lack of documentation could in some cases lead to problems for the patient, as certain increased risks could be overlooked. In conclusion, the use of the Waterlow scale as a risk assessment tool to predict and prevent pressure damage was effective in Elsie’s situation.

Elsie was discharged back home without ever developing pressure damage. Although Elsie would be unable to return to gardening she felt more positive that she would be able to enjoy this again in the future. This outcome was achieved through assessment along with the involvement of the multidisciplinary team in Elsie’s care. However, it should always be remembered that while assessment tools are useful they should never replace clinical judgement, but should work in conjunction with it (National Institute for Clinical Excellence, 2001).


Athorn, S. and Hilton, P. A. (2004). Mobilizing. In P. A. Hilton (eds.) Fundamental Nursing Skills. London: Whurr Publishers Ltd.

Churchill Livingstone’s Dictionary of Nursing (2002). 18th edition. Edinburgh: Churchill Livingstone.

Dealey, C. (2000). The Care of Wounds – A Guide for Nurses. 2nd edition. Oxford: Blackwell Science.

Defloor, T. and Grypdonck, M. (2004). Validation of Pressure Ulcer Risk Assessment Scales: A Critique. Journal of Advanced Nursing. 48(6), 613-621.

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