ISPN/RN考試中可能會出現計算燒傷面積的題目，因為在美國這項工作是急診及相關科室的護士負責。今天這篇文章就給大家分享一下燒傷Burn的分度以及解答這類題目的技巧。

Superficial Thickness(1st degree)Ⅰ度燒傷

臨床表現:

Epidermis only 表皮損傷

No blistering 不起疱

Dry, red, slightly swollen 創傷處幹燥、紅腫

Blanches to pressure 壓之褪色

Painful to touch 觸痛

Heals spontaneously Healing time is 3-7 days 3-7天自行愈合

No scarring 不留瘢痕

Superficial-Partial Thickness(2nd degree)淺Ⅱ度燒傷

臨床表現

Entire epidermis and upper level dermis is lost傷及整個表皮及真皮淺層

Intact blisters水疱

Moist, weeping 創傷處濕潤、滲出

Blanches to pressure 壓之褪色

Hypersensitive to touch 觸之劇痛

Heals rapidly and spontaneously in 1-2 weeks due to good blood supply 無感染1-2周自愈

Scarring is uncommon 不留瘢痕

Deep-Partial Thickness(deep 2nd degree)深Ⅱ度燒傷

臨床表現

Epidermis and severe damage to dermis傷及真皮乳頭層以下

no blisters 沒有水疱

Blotchy whitish，wet or waxy 傷口呈濕潤或蠟樣的灰白色

Some loss of sensation so less painful 因為感覺神經末梢受損，不怎麼疼

Healing is sluggish(greater than 2 weeks, 4-6weeks)愈合緩慢，超過兩周，一般要4-6周

Scarring and contractures可留瘢痕和瘢痕收縮引起的局部功能障礙

Could benefit from skin grafting 最好是進行皮膚移植

Full Thickness&Subdermal(3rd-4th degree)Ⅲ-Ⅳ度燒傷

臨床表現

Complete loss of epidermis and dermis, even subcutaneous fat, muscles,bone全層皮膚燒傷，可深達皮下組織、肌骨

White and waxy to charred black 創面蠟白甚至炭化

Insensate-no pain 無痛覺

Markedly decrease in blood flow 創面血供明顯減少

Susceptible to infections 極易發生感染

High risk of hypertrophic scarring and contractures 多形成瘢痕，且常造成畸形

Pruritis(itching)is a common complication during rehabilitation 愈合過程巨癢

Must do surgical intervention 必須手術幹預

大家可以這樣記，做題非常好用：

Head 9% (face 4.5%)

Chest 9%

Abdomen 9%

Upper back 9%

Lower back 9%

Front left leg 9%

Back left leg 9%

Front right leg 9%

Back right leg 9%

Left arm 9%

Right arm 9%

Genitalia 1%

當然這是針對成人來說的，大家都知道，寶寶的身材比例不同，頭往往占更大的面積，腿占比例相對縮小。不過掌握上述解題技巧對有ISPN/RN考試就足夠用了。實際臨床上護士做評估一般是使用改良後的“倫-勃法”，也就是把頭、大腿和小腿設置了三個變量，按照年齡和公式去推算。

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