Shea published a grading scheme for pressure sores in 1975.
Examination of the Sore |
Grade |
---|---|
acute inflammatory reaction involving all soft tissue layers of the skin with erythema of skin; moist irregular partial thickness ulceration limited to the epidermis exposing the underlying dermis may be present |
I |
acute inflammatory reaction involving all soft tissue layers with a full thickness skin ulcer involving the dermis; may extend to but not go into the underlying subcutaneous fat |
II |
ulcer extensively involving the subcutaneous fat with undermining of the skin and limited by deep fascia; often necrotic, infected and foul-smelling; patient may be toxic with systemic symptoms |
III |
ulcer has penetrated the deep fascia; extensive soft tissue spread, osteomyelitis and/or septic and dislocated joints; patient usually highly toxic |
IV |
large cavity draining through a relatively small sinus, typically overlying a bony prominence; with/without muscle and bone involvement |
closed |
Grade |
Treatment |
---|---|
I |
local wound care |
II |
local wound care |
III |
surgical debridement |
IV |
radical surgery |
closed |
surgery with wide excision |
Specialty: Dermatology, Surgery, general
ICD-10: ,