🩹 W · Wounds and skin
7
statements6
actual1
risk0
urgentRecommended assessment — CarePath tool: CP-SKIN Skin & Wound Score (interactive scoring) · Validated scales: Braden Scale, TIME wound chart
| Code | Problem statement | Type | Description | First 3 actions |
|---|---|---|---|---|
| W1 | Wound not healing | Actual | A wound stays open or shows little progress over the expected time. | Assess the wound · Treat the cause · Dress as ordered |
| W2 | Heavy wound drainage | Actual | A wound leaks large amounts of fluid and needs frequent dressing care. | Use absorbent dressings · Protect surrounding skin · Measure drainage |
| W3 | Pressure sore present | Actual | Skin and tissue over a bony area has broken down from pressure. | Relieve pressure · Dress as ordered · Turn regularly |
| W4 | Difficulty caring for a stoma | Actual | The person or carer struggles to manage a stoma and its appliance. | Teach and practice · Check skin · Use a skin barrier |
| W5 | Fragile skin or skin tears | Risk | Thin or dry skin tears or bruises easily. | Handle gently · Keep skin moist · Protect limbs |
| W6 | Skin reaction to cancer treatment | Actual | Radiation or drugs cause redness, peeling, or soreness of the skin. | Clean gently · Apply moisturizer as ordered · Advise loose cotton clothes |
| W7 | Rash or skin infection | Actual | Skin shows rash, redness, warmth, or pus from irritation or infection. | Wash hands · Clean skin · Give medicine as ordered |