A nurse is preparing a burn-size estimate for fluid-resuscitation planning. The close-ups show four separate injured sites on the same client. Click the site whose visible depth should be excluded from the total body surface area estimate.

A. A shows a superficial injury with an intact red, dry surface; superficial burns are excluded from the TBSA estimate.

Classify visible depth before estimating area. The intact epidermal surface at A differs from the blistering or open moist surfaces at B and D. A painful-looking red area is not automatically included in a resuscitation burn-size estimate.

The observations are fictional teaching data. Apply the stated context; the selected feature does not by itself replace a complete bedside assessment.

Use the combination of surface integrity, moisture and tissue appearance, not redness or dryness alone.

Use the combination of surface integrity, moisture and tissue appearance, not redness or dryness alone.

B and D show partial-thickness injury and are included. C shows a charred full-thickness appearance and is also included, even though it is dry. Dryness alone cannot distinguish superficial from full-thickness injury.

• Burn depth and inclusion in a fluid-planning estimate — Use the combination of surface integrity, moisture and tissue appearance, not redness or dryness alone.
• Comparison with context — C is also dry, but its charred destroyed surface indicates a deeper injury.