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Reference Guide

Glamorgan Pressure Injury Risk Assessment

Document the appropriate score in the Patient Care Record or relevant MR
Patient risk score should be assessed 1.Daily, 2.When the patient condition changes,
3. When transferred to a new department/unit and 4. Prior to discharge
Interventions and actions should be documented on Pressure Injury Prevention Plan or in
Progress Notes

Pressure Injury Risk Assessment Score
Mobility
Child cannot be moved without great difficulty or 20
deterioration in condition/general anaesthetic
Unable to change his/her position without assistance 15
/cannot control body movement
10
Some mobility, but reduced for age
Normal mobility for age 0 Select one score per

Equipment
Equipment/ objects / hard surface pressing or rubbing on 15 section
skin

Risk Score Category Action Pressure Relieving Devices
Inspect skin at least twice a Constant low pressure foam
10+ At Risk day. Maintain adequate mattress
nutrition and hydration.
Relieve pressure by helping Gel pads for high risk areas
the child move every 2 hours. Alternating pressure overlay

(Refer table 4.2 Pressure Injury Clinical Guideline)

Inspect the skin with each Low Air Loss mattress or overlay
15+ High Risk repositioning. Consider
dietician referral. Reposition Alternating Pressure mattress or
child/ equipment/ devices at overlay
least every 2 hours. (Refer table 4.2 Pressure Injury Clinical Guideline)

Inspect the skin hourly. Low Air Loss mattress
20+ Very High Consider dietician referral.
Risk Reposition child/ equipment/ Alternating Pressure mattress
devices at least every 2
hours. (Refer table 4.2 Pressure Injury Clinical Guideline)

Colour version (final) pressure injury doc 15-1-2010
Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom