Alternating Pressure Care Mattresses and the Waterlow Method

  • Pressure Care Mattresses

Alternating Pressure Care Mattresses and the Waterlow Method

The Waterlow Method, developed by clinical nurse teacher Judy Waterlow in 1985 is one of several ways of assessing an individual’s risk of developing pressure injury. Pressure injuries most commonly occur on the bony prominences of the body such as the elbows, heels, hips and the lower back. Any person who is incapable of moving about every 20 minutes or so is at risk of developing pressure injuries.

What is a pressure care injury?

A pressure injury, also called a pressure ulcer or bed sore, usually develops in stages from reddened or blackened skin with pain through to a severe injury where the protective layer of the skin has become an open wound and in the worst cases tissue breakdown has occurred down to bone level. This type of injury as well as causing great pain to the sufferer, requires an enormous amount of effort to repair as well as considerable cost. Early risk assessment and preventative measures are a valuable part of patient care.

How does the Waterlow method work?

Under the Waterlow Method the following areas are assessed for each patient and assigned a point value:

  • Build/weight for height
  • Skin type/visual risk areas
  • Sex and age
  • Malnutrition Screening Tool
  • Continence
  • Mobility

Additional points in special risk categories are assigned to selected patients including:

  • Tissue malnutrition
  • Neurological deficit
  • Major surgery or trauma

Potential scores range from 1 to 64. A total Waterlow score of 10 or greater indicates risk for pressure ulcer. A high risk score is equal to or greater than 15. A very high risk exists at scores equal to or greater than 20.

Any person identified as having potential risk for pressure care injuries has to be carefully managed.

A Pressure Injury Prevention and Management Plan (PIPP) aims to reduce factors associated with pressure injury development and includes interventions that minimise or eliminate friction and shear, minimise pressure with off loading, manage moisture, and maintain adequate nutrition and hydration. 1

Friction and shear

Friction wounds are caused when the skin is rubbed against another object. For example, a bedbound person and bed sheets being dragged across the body as they are repositioned or moved in and out of bed. Shear wounds occur when forces moving in opposite directions are applied to tissues in the body. This can occur when the skin is stuck to a surface, such as a bed sheet, while gravity forces the body downward on the bed, for example whilst a person is sitting up in bed, their back is against the bed and the pressure moves to the base of the back.

As the skin and bones move down due to gravity, blood vessels that are located between the skin and bones can become pinched, which can decrease blood flow to the area. This lack of blood flow in the lower back, in addition to the shearing forces, can cause wounds to form. Shearing wounds usually occur to tissues below the skin surface.

Wounds such as pressure ulcers are caused by both friction and shear forces. Friction will damage the superficial tissue such as the skin, while shearing forces will damage the underlying tissue such as the fat and muscle.

How can the correct mattress help prevent pressure care injuries?

There is a wide variety of tools available to assist in the prevention of pressure injury. One of the most important considerations is the type of mattress. Most people vulnerable to developing these injuries may be either bed bound, chair bound or both. Preventive measures are categorised as either static (reactive) or dynamic (active).

Static pressure care management

A static device is designed to increase conformability to body contours and reduce surface tension or provide constant low pressure. In effect they redistribute pressure but DO NOT REMOVE pressure.   Static devices which includes foam mattresses and various overlays are suitable for people at low/medium risk who can reposition themselves at least every 20 minutes.

There are a range of foam pressure care mattresses available. A suitable foam mattress needs to be:

  • Grade – heavy duty and high resilience
  • Depth of 125 to 150mm
  • Support – hardness /density (130/35)
  • Comfort – side walls

The cover needs to be:

  • Stretch/low shear
  • Waterproof
  • Vapour permeable
  • Fire retardant 2

Bubblemat overlays placed on top of a regular mattress can also assist people with low risk who are mobile.

When should an alternating pressure care mattress be used?

Anyone with a Waterlow Score equal to or greater than 10 needs a higher degree of intervention – usually a dynamic device. A ‘dynamic’ device means that it is plugged into an external power source. The most established type of dynamic device used in the prevention/treatment of pressure injury is the alternating pressure care mattress. This dynamic /active product provides alternate inflation and deflation of air cells (bladders) to constantly change pressure points and promote circulation.

How does the alternating air cells of the mattress benefit the body?

The alternating mattress encourages:

  • normal physiological response of the body
  • removal of toxic wastes
  • reperfusion of previously ischaemic tissue (restoration of blood flow to an area previously blocked)
  • increased blood supply
  • increased oxygenation

An alternating pressure care mattress gives a high risk person the best possible protection against developing pressure injuries owing to immobility for extended periods of time.

What factors should be considered when selecting an alternating air cell mattress?

Specific things to consider to assist in identifying which type of alternating air cell mattress to use for a particular person include:

  • will it be an overlay or a mattress replacement?
  • cell height
  • cycle time
  • noise level
  • any special needs

The cover needs to be:

  • stretchable/low friction material
  • waterproof
  • vapour permeable
  • cleanable/replaceable 3

An untreated pressure ulcer can lead to death. Lack of mobility as a result of underlying medical conditions, severe body trauma or being excessively overweight or underweight can all contribute to the risk of pressure injury. Any factors leading to skin breakdown including friction and shear forces, moisture build up, malnutrition and acute infection hasten the development of pressure injury unless assessment and intervention is implemented. With appropriate care, up to 90% of pressure ulcers can be prevented. 4


1 National Safety and Quality Health Service (NSQHS) Standard 8 Pressure Injury – Definitions sheet. P.8. Accessed: 23 November 2017 at:, 3, 4 Curry, Annette. Principles of Pressure Care and Mattress Selection. Accessed on 20 November 2017 at:

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Alternating Pressure Care Mattresses and the Waterlow Method

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The Waterlow Method, developed by clinical nurse teacher Judy Waterlow in 1985 is one of several ways of assessing an individual’s risk of developing pressure injury. Pressure injuries most commonly occur on the bony prominences of the body such as the elbows, heels, hips and the lower back. Any person who is incapable of moving about every 20 minutes or so is at risk of developing pressure injuries.

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