Education and care-planning support only — does not replace clinical judgment or local protocols.

🩺 CP-SKIN — Skin & Wound Score

Pressure injury and wound risk. · Group W Wounds and skin · Links to: W1–W7, S5

Original tool, not yet validated. Pilot and review with clinicians before clinical decisions. Supports, but does not replace, clinical judgment, validated scales and local policy.

Patient

Date/Time

Nurse

Item	0	1	2
Moves in bed	0 · Changes position alone	1 · Needs help sometimes	2 · Cannot change position
Skin moisture	0 · Dry	1 · Sometimes damp	2 · Often wet (sweat, urine)
Nutrition	0 · Eats well	1 · Eats half	2 · Eats little
Skin over bony areas	0 · Intact	1 · Red but fades on pressing	2 · Red that does not fade or broken
Wound (if present)	0 · Healing, clean	1 · Slow, some drainage	2 · Smell, pus, spreading red

⚠ Red flags — escalate at once regardless of score

Spreading redness with fever

Total: 0 — select a score for each item

Score	Level	Action
0–2	Low	Check skin daily
3–5	Medium	Turn every 2–4 h, pressure-relief mattress
≥6	High	Turn every 2 h, wound plan, tissue-viability referral

Nursing notes / action taken

⬇ Blank form (PDF)