Shea published a grading scheme for pressure sores in 1975.
Examination of the Sore
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
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
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
ulcer has penetrated the deep fascia; extensive soft tissue spread, osteomyelitis and/or septic and dislocated joints; patient usually highly toxic
large cavity draining through a relatively small sinus, typically overlying a bony prominence; with/without muscle and bone involvement
local wound care
surgery with wide excision
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Specialty: Dermatology, Surgery, general