HISTORY. Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important since any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the accident, since closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking health care, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members.

PHYSICAL EXAMINATION. Although the wounds of a serious burn injury may be dramatic, a basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine the severity of injury. The American Burn Association (ABA) establishes the severity of injury by calculating the total body surface area (TBSA) of partial and full-thickness injury along with the age of the patient and other special factors (Table 7).

The "rule of nines" is a practical technique used to estimate the extent of TBSA involved in a burn. The technique divides the major anatomic areas of the body into percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient's palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient's response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and output monitoring are essential to ensure that the patient is responding appropriately to treatment.

PSYCHOSOCIAL ASSESSMENT. Even small burns temporarily change the appearance of the skin. Major burns will have a permanent effect on the family unit. A complete assessment of the family's psychological health before the injury is essential. Expect preexisting issues to magnify

• TABLE 7 Characteristics of Burns
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