W2 · Heavy wound drainage
Actual Wounds and skin
Definition
A wound leaks large amounts of fluid and needs frequent dressing care.- Infection
- large wound
- swelling
- fistula
- Soaked dressings
- odor
- damaged skin around the wound
📋 Scenario
A surgical wound soaks its dressings every few hours.
Subjective (S): "The dressing is soaked again."
Objective (O): Large wound; drainage soaks the dressing every 3 hours; surrounding skin red.
Assessment tools for this scenario: CP-SKIN Skin & Wound Score
Validated scales to consider: Braden Scale, TIME wound chart
**CarePath diagnosis:** Heavy wound drainage related to infection, as evidenced by soaked dressings and odor.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Use absorbent dressings. | Absorbent dressings hold large amounts of fluid away from the wound and skin, which keeps the area cleaner and reduces odor. |
| Protect surrounding skin. | Constant moisture softens skin and causes breakdown, so a barrier or protective product keeps the red skin around the wound from worsening. |
| Measure drainage. | Measuring or estimating drainage shows whether it is rising or falling, which guides dressing choice and shows whether treatment works. |
| Report increases. | A rise in drainage may mean infection or other complications, so telling the team quickly allows early treatment. |
**Expected outcomes**
- Drainage reduced.
- Dressing changed on schedule.
- Skin around the wound intact.
**Linking the data to the diagnosis**
The patient says, 'The dressing is soaked again.' The wound is large, the dressing is soaked every 3 hours and the surrounding skin is red. The excess drainage is already occurring, so an actual statement fits, and the evidence is soaked dressings and odor. It is chosen over a general wound statement because the main task is managing fluid and protecting skin. The plan aims for drainage to reduce, dressings to be changed on schedule and the skin around the wound to stay intact.
CarePath diagnosis
Heavy wound drainage related to infection, as evidenced by soaked dressings and odor.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Use absorbent dressings. | Absorbent dressings hold large amounts of fluid away from the wound and skin, which keeps the area cleaner and reduces odor. |
| 2. Protect surrounding skin. | Constant moisture softens skin and causes breakdown, so a barrier or protective product keeps the red skin around the wound from worsening. |
| 3. Measure drainage. | Measuring or estimating drainage shows whether it is rising or falling, which guides dressing choice and shows whether treatment works. |
| 4. Report increases. | A rise in drainage may mean infection or other complications, so telling the team quickly allows early treatment. |
Expected outcomes
- Drainage reduced.
- Dressing changed on schedule.
- Skin around the wound intact.
Linking the data to the diagnosis
The patient says, 'The dressing is soaked again.' The wound is large, the dressing is soaked every 3 hours and the surrounding skin is red. The excess drainage is already occurring, so an actual statement fits, and the evidence is soaked dressings and odor. It is chosen over a general wound statement because the main task is managing fluid and protecting skin. The plan aims for drainage to reduce, dressings to be changed on schedule and the skin around the wound to stay intact.