TEMPLATE test waterlow (test waterlow)

TEMPLATE IDtest waterlow
Concepttest waterlow
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Silje Ljosland Bakke; organisation: Helse Vest IKT AS; email: silje.ljosland.bakke@helse-vest-ikt.no; date: 2020-10-12
Other Details Languagename: Silje Ljosland Bakke; organisation: Helse Vest IKT AS; email: silje.ljosland.bakke@helse-vest-ikt.no; date: 2020-10-12
Other Details (Language Independent)
  • Original Language: ISO_639-1::en
Language useden
Citeable Identifier1013.26.989
Root archetype idopenEHR-EHR-OBSERVATION.waterlow_score.v0
test waterlowtest waterlow: The Waterlow Score, Pressure Ulcer Risk Assessment Tool.
Data
Any eventAny event: Any event.
Data
SexSex: Risk conferred by the sex of the subject.
  • 1: Male 
  • 2: Female 
Age groupAge group: Risk conferred by the age range of the subject.
  • 0: Less than 14 years 
  • 1: 14-49 
  • 2: 50-64 
  • 3: 65-74 
  • 4: 75-80 
  • 5: 80+ 
Build/weight for heightBuild/weight for height: Risk conferred by the subject's build, based on a BMI calculation.
  • 0: Average 
  • 1: Above average 
  • 2: Obese 
  • 3: Below average 
ContinenceContinence: Risk conferred by the subject's degree of continence.
  • 0: Complete / catheterised 
  • 1: Urinary incontinence 
  • 2: Faecal incontinence 
  • 3: Urinary and faecal incontinence 
MobilityMobility: Risk conferred by the mobility level of the subject.
  • 0: Fully mobile 
  • 1: Restless/ fidgety 
  • 2: Apathetic 
  • 3: Restricted 
  • 4: Bedbound 
  • 5: Chairbound 
Nutritional riskNutritional risk: An estimate of nutritional risk based on the MST nutritional score but can make use of another compatible nutritional score.
Weight lossWeight loss: Risk conferred by recent weight loss.
  • 0: No recent weight loss 
  • 1: 0.5-5kg 
  • 2: 5-10kg (or Amount unsure) 
  • 3: 10-15kg 
  • 4: Over 15kg 
AppetiteAppetite: Risk conferred by the subject's appetite and eating habit.
  • 0: Average 
  • 1: Poor 
Nutritional scoreNutritional score: The nutritional score total, derived from Appetite and Weight loss scores or recorded directly from another compatible nutritional scoring system.
0..5
Skin type visual risk areasSkin type visual risk areas: Category of risks assessed by skin inspection.
HealthyHealthy: The skin appears healthy.
  • 0: Healthy 
Tissue-paperTissue-paper: The skin has a tissue-paper quality.
  • 1: Tissue-paper 
DryDry: The skin is dry.
  • 1: Dry 
OedematousOedematous: The skin is oedematous.
  • 1: Oedematous 
Clammy, pyrexiaClammy, pyrexia: The aptient appears clammy or pyrexic.
  • 1: Clammy, pyrexia 
Discoloured - Stage 1Discoloured - Stage 1: The skin is dicoloured - Pressure sore - Grade 1.
  • 2: Discoloured - Stage 1 
Pressure ulcer - Stage 2-4Pressure ulcer - Stage 2-4: The skin has a frank pressure sore - Stage 2-4.
  • 2: Pressure ulcer - Stage 2-4 
Tissue malnutritionTissue malnutrition: Category of risks conferred by tissue malnutrition.
Terminal cachexiaTerminal cachexia: The subject is terminally-ill and shows significant weight-loss.
  • 8: Terminal cachexia 
Single organ failureSingle organ failure: The patent has single organ/system failure e.g. respiratory, cardiac, liver, renal.
  • 5: Single organ failure 
Multiple organ failureMultiple organ failure: The subject has multiple organ/system failure.
  • 8: Multiple organ failure 
Peripheral vascular diseasePeripheral vascular disease: The subject has peripheral vascular disease.
  • 5: Peripheral vascular disease 
Anaemia (Hb < 8 g/dl)Anaemia (Hb < 8 g/dl): The subject is significantly anaemic. Hb less than 8 mg/dl.
  • 2: Anaemia (Hb < 8 g/dl) 
SmokingSmoking: The subject is a smoker.
  • 1: Smoking 
Neurological deficitNeurological deficit: Risk conferred by neurological deficit. Each identified risk can be scored between 4-6 but a maximum of 6 only can be given for the whole neurological deficit category.
Diabetes, MS, CVADiabetes, MS, CVA: The subject has diabetes, multiple sclerosis or has had a stroke.
  • 0: No neurological deficit 
  • 4: Mild neurological deficit 
  • 5: Moderate neurological deficit 
  • 6: Severe neurological deficit 
Motor / sensory deficitMotor / sensory deficit: The subject has a motor or sensory deficit.
  • 0: No neurological deficit 
  • 4: Mild neurological deficit 
  • 5: Moderate neurological deficit 
  • 6: Severe neurological deficit 
ParaplegiaParaplegia: The subject has a paraplegia.
  • 0: No neurological deficit 
  • 4: Mild neurological deficit 
  • 5: Moderate neurological deficit 
  • 6: Severe neurological deficit 
Combined neurological deficitCombined neurological deficit: An overall estimate of neurological deficit. Should not be used if individual neurological deficit risks are recorded.
  • 0: No neurological deficit 
  • 4: Mild neurological deficit 
  • 5: Moderate neurological deficit 
  • 6: Severe neurological deficit 
Major surgery or traumaMajor surgery or trauma: Risk associated with major surgery or trauma.
Orthopaedic /spinalOrthopaedic /spinal: Risks related to orthopaedic or spinal surgery.
  • 0: No orthopaedic / spinal surgery 
  • 5: Orthopaedic /spinal surgery 
Duration of surgeryDuration of surgery: Risks imparted by length of surgery.
  • 0: On table < 2 hrs or not in ast 48 hrs 
  • 5: On table > 2 hrs (Past 48 hrs) 
  • 8: On table > 6 hrs (Past 48 hrs) 
MedicationMedication: Risk associated with medication. Each medication can be scored between 0-4 but a total of 4 only can be given by all risks in the Medication category.
CytotoxicsCytotoxics: The subject is receiving cytotoxic medication.
  • 0: No medication risk 
  • 4: Significant medication risk 
SteroidsSteroids: The subject is receiving high-dose or long-term steroid medication.
  • 0: No medication risk 
  • 4: Significant medication risk 
Anti-inflammatoriesAnti-inflammatories: The subject is receiving anti-inflammatory medication.
  • 0: No medication risk 
  • 4: Significant medication risk 
Combined medication riskCombined medication risk: Overall pressure ulcer risk related to medication. Should not be recorded if individual medication risks are used.
  • 0: No medication risk 
  • 4: Significant medication risk 
Waterlow scoreWaterlow score: The total summed score of all recorded individual risks.
1..49
Overall risk gradeOverall risk grade: Overall Waterlow Score.
  • 10: 10+ At risk 
  • 15: 15+ High risk 
  • 20: 20+ Very high risk 
CommentComment: Additional narrative comment about the Score.
State
Confounding factorsConfounding factors: Issues that may affect interpretation of the score.
Protocol
Score versionScore version: The version of the score used, normally recorded as the year.