Glamorgan Pressure Injury Risk Assessment
Glamorgan Pressure Injury Risk Assessment is a reference guide to determine whether the patient is at risk, high risk or very high risk of having a pressure injury.
NOTE: It is very important the patient to be assessed by a qualified healthcare professional. Please contact your doctor or your local hospital for assistance.
PRESSURE INJURY RISK ASSESSMENT |
SCORE |
SELECT ONE SCORE PER SECTION |
|
MOBILITY |
|||
|
Child cannot be moved without great difficulty or deterioration in condition/general anaesthetic |
20 |
|
Unable to change his/her position without assistance /cannot control body movement |
15 |
||
Some mobility, but reduced for age |
10 |
||
Normal mobility for age |
0 |
||
EQUIPMENT |
|||
|
Equipment/ objects / hard surface pressing or rubbing on skin |
15 |
RISK SCORE |
CATEGORY |
ACTION |
PRESSURE RELIEVING DEVICES |
10+ |
At Risk |
Inspect skin at least twice a day. Maintain adequate nutrition and hydration. Relieve pressure by helping the child move every 2 hours. |
Constant low-pressure foam mattress Gel pads for high risk areas Alternating pressure overlay (Refer table 4.2 Pressure Injury Clinical Guideline) |
15+ |
Inspect the skin with each repositioning. Consider dietician referral. Reposition child/ equipment/ devices at least every 2 hours. |
Low Air Loss mattress or overlay Alternating Pressure mattress or overlay (Refer table 4.2 Pressure Injury Clinical Guideline) |
|
20+ |
Inspect the skin hourly. Consider dietician referral. Reposition child/ equipment/ devices at least every 2 hours. |
Low Air Loss mattress Alternating Pressure mattress (Refer table 4.2 Pressure Injury Clinical Guideline) |
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