Pressure sores

Question 1

Pressure sore stages

Answer 1

Stage 1: Category 1: Non-blanchable redness of intact skin

Stage 2: Partial thickness skin loss or blister

Stage 3: Full thickness skin loss (fat visible, but not bone/muscle)

Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle

Question 2

How often should at-risk patients be repositioned?

Answer 2

Every 6 hours for those at risk, and every 4 hours for those at high risk

Question 3

what is the Waterlow Score?

Answer 3

The Waterlow classification is a risk assessment tool used to estimate a patient’s risk of developing a pressure sore (pressure ulcer).

Does not stage an pressure sore

Question 4

What are the key features in the Waterlow score?

Answer 4

• BMI
• Skin Type/Visual Risk Areas
• Sex and Age
• Continence
• Mobility
• Nutrition
• Special Risk Factors

Question 5

What are the high risk scores on the Waterlow score

Answer 5

Interpretation of Scores:

10–14: At risk

15–19: High risk

20 or above: Very high risk