Exam 2 · Week 4 · Standalone study page
M4 · Burns
This page keeps all of the original course information, while reducing the decision to one module: airway, burn depth, fluids and wound care.
▸M4BurnsWeek 4
💡 The one idea
A major burn is a fluid problem before it is a skin problem. Capillaries leak plasma into the tissue, so the patient dies of hypovolemia, not of the wound.
First 24 hours = fluids. After 48 hours = infection.
| Depth | Layers | Looks like | Pain |
|---|---|---|---|
| Superficial | Epidermis | Red, dry, blanches | Painful |
| Partial thickness | Into dermis | Blisters, moist, weeping | MOST painful |
| Full thickness | Through dermis | White, leathery, waxy, dry | Painless — nerves destroyed |
| Deep full thickness | Into muscle/bone | Charred, blackened | Painless |
🚨 Painless is worse, not better
A patient who cannot feel the burn has destroyed nerve endings. Never read absent pain as a good sign.
⭐ Rule of Nines — adult
- Head & neck — 9%
- Each arm — 9% (front 4.5 + back 4.5)
- Each leg — 18% (front 9 + back 9)
- Front torso 18% · Back torso 18%
- Perineum — 1%
Children have proportionally bigger heads, so pediatric charts shift percentage from the legs to the head.
💧 Parkland formula — and the half that trips people
4 mL × kg × %TBSA Lactated Ringer’s, over 24 hours — timed from the moment of the burn, not from arrival at hospital.
Half in the first 8 hours. The other half over the next 16.
Worked example — 70 kg, 50% TBSA:
4 × 70 × 50 = 14,000 mL total →
7,000 mL in 8 h (~875 mL/h), then 7,000 mL over 16 h (~437 mL/h).
✅ The best indicator that fluids are working
Urine output — adults 30–50 mL/hr, children 1 mL/kg/hr.
Not blood pressure, not heart rate. Urine output is the perfusion number the exam wants.
🔥 Airway comes before all of it
Suspect inhalation injury with: facial burns, singed nasal hair, soot in the mouth, hoarseness, stridor, carbon in sputum, or any burn in an enclosed space.
Airway swelling worsens fast. Intubate early - waiting until distress is visible can be too late.
⭐ High-yield — what the exam actually asks
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- Face, neck or chest burns → airway is the priority. Assess breathing before you estimate TBSA or start fluids. Waist-down burns → fluids are the priority.
- Airway red flags: singed nasal hair or eyebrows, carbonaceous sputum, hoarseness, stridor, drooling or trouble swallowing, falling SpO2.
- Rule of Nines: head/neck
9, each arm9(4.5 front / 4.5 back), anterior trunk18, posterior trunk18, each leg18, perineum1. Know the sub-fractions — the front of a forearm is ~2.25%, not 4.5%. - Her palm including fingers ≈ 1% TBSA, used for scattered irregular burns.
- Parkland:
4 mL × kg × %TBSAof LR over 24 hr. First half in the first8 hrtimed from the injury, not from arrival; second half over the next16 hr. Count only 2nd- and 3rd-degree burns.
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- Target urine output
≥30 mL/hrin adults — that is how you know resuscitation is working. - Depth: superficial = red, dry, no blisters. Superficial partial = blisters, moist, very painful. Deep partial = mottled/waxy, less painful. Full-thickness = white/leathery, painless. 4th degree = into muscle or bone.
- Burn labs from cell death: sodium down, potassium up, uric acid up, H&H falsely high from hemoconcentration.
- Phases: emergent (0–48 hr — airway, fluids, prevent shock), acute (wound care, infection, nutrition, pain), rehabilitative (contractures, scarring, psychosocial).
- Escharotomy relieves circulation through eschar; fasciotomy goes deeper for compartment syndrome. Silver sulfadiazine topically; premedicate before every dressing change.
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- Big burns (60–70%): infection, hypothermia, compartment syndrome, and fluid overload after the first 24 hours.
🎧 From the LSC exam-prep recording
What the faculty actually said in the review session for this week — their numbers, their worked calculations, their priority rulings. On an exam, this beats the textbook.
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- Rule of nines as they drilled it: head/neck 4.5 front + 4.5 back · each arm 9 · each leg 18 · anterior trunk 18 · posterior trunk 18 · perineum 1. Their vocabulary trap: "torso" means chest AND abdomen = 18; "anterior chest" alone is 9.
- First-degree burns are never counted in TBSA or in Parkland. You have to be at partial thickness or deeper.
- Parkland as taught here: 4 mL × kg × %TBSA over 24 h, half in the first 8 h. Lactated Ringer's, always — they said burn centers are "very sensitive about this" and there will be a silence on the phone if normal saline is hanging.
- Their worked problems: 63 kg / 58.5% → 921 mL/hr · 75 kg / 54% → 1,013 mL/hr (165 lb ÷ 2.2 = 75 kg first) · 100 kg / 47% → 1,175 mL/hr.
- Calc: morphine 1 mcg/kg/min, 198 lb = 90 kg, supplied 50 mg/100 mL → 90 mcg/min →
0.09 mg/min→5.4 mg/hr→11 mL/hr. Their advice: once you know it is math, stop caring that it is morphine and carry your units through every line.
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- Hourly urine output is the most reliable indicator of adequate resuscitation — not blood pressure (too variable), not daily weight (too slow), not the infusion rate (that only says what went in). An under-resuscitated kidney simply stops releasing fluid.
- Urine output: 30 mL/hr is the floor, not the target — they want 50–60. Below 0.5 mL/kg/hr → fluid challenge and increase the rate. Parkland is only a starting rate; titrate to output. Their line: we treat people, not numbers.
- Their trend SATA — urine 35 → 25 → 15 mL, BP 90/58 → 82/50, HR 118 → 132, alert → lethargic: notify the provider of hypovolemic shock, increase the fluid rate per protocol, prepare for a central line (peripheral lines cannot take the flow). No diuretics, no vasopressors, and do not "reassess in 2 hours."
- Why not vasopressors: always ask what the underlying problem is. Here it is lost volume, so the answer is fluid. Vasopressors belong to septic shock.
- In the emergent phase the priority is fluid resuscitation with crystalloids — not pain control, not antibiotic ointment, not debridement. In the emergent phase the answer is never infection or wound care; infection is days away. If the phase is not stated, derive it from context, because the priorities flip.
- 30% TBSA arriving in the ED: two large-bore IVs first, before analgesia or removing clothing. Crystalloid = water plus electrolytes (NS, LR — about 97% of what hangs in a hospital); colloid = protein (albumin, dextran), used to pull fluid into the vessels.
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- Burn depth by description: first = erythema only, like sunburn · second = clear fluid blisters with surrounding redness, very painful · third = dry, leathery, painless · fourth = charred to muscle and bone. Painless is the frightening one — the nerves have burned through.
- Triage among burn clients: face and airway beat a larger %TBSA. Inhalation cues — singed nasal hair, hoarseness, carbonaceous sputum, brassy cough → get intubation equipment now, because in 1–2 hours the airway swells shut. Even with no skin burns, an enclosed-space history still drives the priority.
- Enclosed-space fire means more than the burn: carbon monoxide and cyanide from burning furniture. Check for both.
- Circumferential chest burn → impaired ventilation is the immediate risk, not shock and not infection — the tight eschar is a belt around the chest. Around a limb it is ischemia instead. The fix is an escharotomy (through the burned skin) or a fasciotomy (deeper).
- Systemic effects they scored correct: hyperkalemia (cells rupture and dump potassium), hyponatremia (sodium follows fluid into the third space), paralytic ileus, decreased cardiac output, hypothermia (skin regulates temperature), Curling's ulcer. Scored wrong: increased cardiac output, metabolic alkalosis, hypoglycemia — it is metabolic acidosis and hyperglycemia.
- Home first aid: cool running water a full 20 minutes, no ice (it vasoconstricts), do not break blisters — the blister is the dressing — no petroleum jelly, no adhesive bandage, check tetanus, and remove rings and tight jewelry before the swelling makes them uncuttable.
- Pressure garments: about 23 hours a day — the missing hour is for washing and drying a spare set, which also prevents fungal skin problems — for up to 24 months. They should not be painful. Pain means a poor fit or a problem, and is a report-it finding.
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- ABC is not the only prioritization framework. Theirs: ABC, then Maslow, nursing process, unstable before stable, acute before chronic, least invasive first. And ABC has a D — disability, the neuro check — which comes after C.
- Their two opposite mistakes: missing an ABC problem and answering the brain instead, or choosing an ABC answer when there is no ABC problem. Do not give oxygen to a client whose SpO₂ is 97%. If confusion sits next to a BP of 70/50, the blood pressure is the priority and probably the cause.
⚠️ Exam traps
- Full-thickness burns are painless but the partial-thickness skin around them hurts intensely. "No pain" does not mean "not serious."
- First-degree burns are excluded from the Parkland calculation.
⚠️ What it turns into — the complication for each one
The disorder cards below run definition, causes, signs, diagnostics, management and nursing. This is the part they do not have, and it is where the exam lives: so what happens if this is missed or left? The order changes with time. In the first 48 hours the danger is airway and fluid; after that it is infection, and later it is contracture.
| Disorder | What it turns into |
|---|---|
| Burn depth and classification | Depth judged too shallow means under-resuscitation. A circumferential full-thickness burn acts as a tourniquet — compartment syndrome of the limb, or of the chest, stopping ventilation. Escharotomy is the answer |
| Emergent (resuscitative) phase | Hypovolaemic burn shock, acute kidney injury from hypoperfusion and myoglobin, hyperkalaemia as cells lyse, hypothermia, paralytic ileus and Curling ulcer |
| Acute and rehabilitative phases | Infection and sepsis — the leading cause of death after a burn. Then contractures, hypertrophic and keloid scarring, huge protein-calorie deficit, and depression and PTSD |
| Inhalation injury | Airway obstruction as the swelling develops — which is why intubation comes before it, not after. Then ARDS, carbon monoxide and cyanide poisoning, and pneumonia |
| Electrical and chemical burns | Dysrhythmia and cardiac arrest, rhabdomyolysis causing acute kidney injury, deep destruction under skin that looks intact, fractures and dislocations from tetanic contraction, and cataracts months later |
🔥 Burns, section by section
The classification and the three phases, plus the two injuries whose surface appearance lies to you. Same six sections every time.
Burn Depth and ClassificationOpenClose
Definition and Overview
Burns are classified by how deep the injury goes, and depth decides everything that follows — pain, healing time, whether grafting is needed, and how much fluid the person will lose. Superficial (first-degree) involves the epidermis only. Partial-thickness (second-degree) reaches into the dermis. Full-thickness (third-degree) destroys the entire dermis, and fourth-degree goes through to fat, muscle or bone.
Causes and Risk Factors
Thermal (flame, scald, contact) is the most common. Then chemical, electrical, radiation and inhalation. Risk is highest at the extremes of age — infants and older adults have thinner skin, so the same heat for the same time burns them deeper. Add impaired mobility, sensory or cognitive impairment, unsafe heating, smoking, alcohol, and occupational exposure.
Clinical Manifestations
Superficial: red, dry, painful, blanches, no blisters — sunburn. Heals in about 3–6 days. Partial-thickness: moist, red or mottled pink, blisters, blanches, and very painful because the nerve endings are exposed and intact. Heals in 2–3 weeks. Full-thickness: dry, leathery, waxy white, tan or charred, does not blanch, and is painless in the center because the nerve endings are destroyed — a burn that does not hurt is worse, not better. It will not heal without grafting.
Assessment and Diagnostic Findings
Estimate extent with the Rule of Nines in an adult: head 9%, each arm 9%, each leg 18%, front of trunk 18%, back of trunk 18%, perineum 1%. For scattered burns, the client's own palm including the fingers is about 1%. The Lund–Browder chart is more accurate and is what is used in children, because a child's head is proportionally much larger. Note depth, extent, location, age and inhalation injury — those are what decide transfer to a burn center. Burns of the face, hands, feet, perineum or a joint, and any circumferential burn, are major regardless of size.
Medical Management
Depth decides it. Superficial burns need cooling, analgesia and moisturiser. Partial-thickness burns need cleaning, a topical antimicrobial and dressings, and possibly excision and grafting if deep. Full-thickness burns need surgical excision and skin grafting — usually an autograft from the client's own unburned skin. Tetanus prophylaxis for everyone.
Nursing Management and Client Education
Stop the burning process first: remove the client from the source, take off burned clothing and all jewellery before swelling starts, and cool a small burn with room-temperature water, never ice. Cover with a clean dry sheet and keep the client warm — a large burn loses heat fast and hypothermia is a real risk. Never break blisters, and never put butter, ointment, ice or anything else on a fresh major burn. For a chemical burn, brush off dry powder first, then flush with running water for at least 20 minutes. Teach that healing skin must be moisturised and kept out of the sun for a year.
Emergent (Resuscitative) PhaseAirway first, then fluidsOpenClose
Definition and Overview
The first 24 to 48 hours after a major burn. Capillaries everywhere become leaky, so plasma pours out of the vessels into the tissues — this is burn shock, a hypovolaemic shock caused by fluid shifting, not by bleeding. The phase ends when the capillaries seal and the fluid starts coming back.
Causes and Risk Factors
Any burn over about 20% total body surface area in an adult, or 10% in a child or older adult, produces this systemic response. Electrical burns and inhalation injury make it worse than the surface area suggests.
Clinical Manifestations
Hypovolaemia: tachycardia, falling blood pressure, thirst, urine output under 30 mL/hr, and massive edema in and around the burn. Labs show the fluid shift as haemoconcentration — a high hematocrit — with hyperkalaemia from cells breaking open and hyponatraemia from sodium moving into the tissues. Metabolic acidosis. Bowel sounds go quiet as a paralytic ileus develops.
Assessment and Diagnostic Findings
Airway before anything else — hoarseness, stridor, singed nasal hairs, soot in the mouth, facial burns or carbonaceous sputum mean the airway is going to swell shut, and it is intubated before that happens, not after. Carboxyhaemoglobin level in any enclosed-space fire; pulse oximetry reads falsely normal in carbon monoxide poisoning. Hourly urine output through an indwelling catheter is the single best measure of whether resuscitation is working. Daily weight, hourly vital signs, electrolytes, ABGs, and circulation checks distal to any circumferential burn.
Medical Management
Fluid resuscitation with lactated Ringer's, by the Parkland (Consensus) formula: 4 mL × kg × %TBSA. Half of that total goes in over the first 8 hours, counted from the time of the burn and not from arrival; the other half over the following 16 hours. The formula is only a starting point — the rate is titrated to urine output of 30–50 mL/hr in an adult. 100% oxygen for suspected carbon monoxide poisoning. IV opioids in small frequent doses. Escharotomy for a circumferential burn that is cutting off circulation or chest expansion. Nasogastric tube for the ileus, and stress-ulcer prophylaxis.
Nursing Management and Client Education
Airway, breathing, circulation, in that order — on this page and on the exam. Two large-bore IVs, ideally through unburned skin. Titrate the fluid to the hourly urine output and report output under 30 mL/hr. Give analgesia intravenously, never intramuscularly or subcutaneously — with the circulation shut down the drug will not absorb, and will then all absorb at once when perfusion returns. Check pulses, capillary refill, sensation and movement distal to every circumferential burn hourly. Keep the client warm. Elevate burned limbs. Tell the family what is happening; this phase looks terrifying from the bedside.
Acute and Rehabilitative PhasesOpenClose
Definition and Overview
The acute phase begins when the capillaries seal and diuresis starts, and runs until the wounds are closed. It is about wound care, infection and nutrition. The rehabilitative phase overlaps it and runs for months to years: function, scarring and the person's life afterwards.
Causes and Risk Factors
Everything that goes wrong here follows from the wound being open and the metabolism being enormous. Risk rises with the size and depth of the burn, age, malnutrition, pre-existing illness, and invasive lines and catheters.
Clinical Manifestations
Fluid comes back into the vessels, so hematocrit falls and urine output rises. Hypokalaemia replaces the earlier hyperkalaemia as potassium moves back into cells and is lost in the urine. A hypermetabolic state — the resting energy requirement can double — brings weight loss and muscle wasting. Watch for infection: the earliest signs of burn wound sepsis are subtle — confusion, a falling temperature, ileus and rising glucose — not a spiking fever. Later, hypertrophic scars and contractures across joints.
Assessment and Diagnostic Findings
Daily wound assessment for color, odour, exudate and the state of the graft. Wound and blood cultures. Daily weight is the measure of nutritional adequacy, with albumin, prealbumin, glucose and nitrogen balance. Range of motion at every joint, and psychological assessment — depression, grief and post-traumatic stress are expected, not unusual.
Medical Management
Excision of dead tissue and grafting: autograft is permanent, allograft and xenograft are temporary cover. Topical antimicrobials such as silver sulfadiazine or mafenide. High-protein, high-calorie nutrition, started enterally and early — tube feeding within the first day or two if the client cannot eat enough. Pain management through every dressing change. Pressure garments for 12–24 months to control scarring, splinting to prevent contracture, and physiotherapy.
Nursing Management and Client Education
Infection is the leading cause of death after a burn, and your hands are the main vehicle. Strict aseptic technique, gown and gloves, dedicated equipment, and no flowers, plants or fresh fruit in the room. Medicate for pain 30 to 45 minutes before a dressing change, not during it. Push protein and calories at every opportunity and record what is actually eaten. Position to prevent contracture, which means positioning against the position of comfort — the neck extended rather than pillowed, limbs straight and abducted — and range of motion even when it hurts. Teach that pressure garments are worn 23 hours a day, that healed skin needs moisturiser and sun protection, and that itching is normal and treatable. Expect and normalize the grief over appearance, and refer for counselling and to a burn survivor group.
Inhalation InjuryIntubate before the swellingOpenClose
Definition and Overview
Damage to the airway and lungs from breathing in hot gases, smoke or chemical products of combustion. It exists in three forms: upper airway injury from heat, which swells; lower airway and lung injury from chemical irritants, which appears over hours to days; and systemic poisoning from carbon monoxide or cyanide. It roughly doubles the mortality of any given burn.
Causes and Risk Factors
A fire in an enclosed space is the single biggest clue. Then burns to the face or neck, loss of consciousness at the scene, being trapped, and an explosion. Smoke from synthetic materials carries cyanide as well as carbon monoxide.
Clinical Manifestations
Hoarseness, a brassy cough, stridor, singed nasal hairs or eyebrows, soot around the mouth or nose, carbonaceous (black-flecked) sputum, facial burns and difficulty swallowing. Carbon monoxide poisoning gives headache, nausea, dizziness and confusion; the classic cherry-red skin is a late and unreliable sign, and the pulse oximeter reads normal because it cannot tell carboxyhaemoglobin from oxyhaemoglobin. Lower airway injury shows up 24 to 48 hours later as increasing dyspnea, wheezing and hypoxaemia.
Assessment and Diagnostic Findings
History of the fire — enclosed space, how long. Continuous respiratory assessment, looking for a rising respiratory rate, changing voice and increasing stridor. Arterial blood gases with a carboxyhaemoglobin level, because oximetry will mislead you. Chest x-ray is often normal at first. Bronchoscopy confirms the injury and clears the airway.
Medical Management
Early intubation — when the signs are there, the airway is secured before the edema closes it, because once it has closed, intubation may be impossible. 100% humidified oxygen by non-rebreather for carbon monoxide, which cuts its half-life from hours to well under one; hyperbaric oxygen in severe cases. Hydroxocobalamin for cyanide toxicity. Mechanical ventilation, bronchodilators, aggressive pulmonary hygiene and bronchoscopic clearance.
Nursing Management and Client Education
Assume inhalation injury in any burn from an enclosed space and watch the airway continuously — deterioration is measured in minutes. Keep intubation equipment at the bedside. Head of bed elevated. Humidified oxygen, suction, incentive spirometry, coughing and deep breathing, turning every two hours. Report any change in the voice at once. Do not wait for a falling oxygen saturation to act on stridor — by then the airway is nearly closed. Explain to the family why the client is being intubated while still talking; it looks premature and it is not.
Electrical and Chemical BurnsThe surface liesOpenClose
🖼️ InfographicsBurns
Definition and Overview
Two burns where what you can see badly understates what has happened. An electrical burn is really an internal injury: the current travels along the path of least resistance — nerves, blood vessels and muscle — cooking tissue between an entry and an exit wound that may each look small. A chemical burn goes on burning for as long as the agent is in contact with skin.
Causes and Risk Factors
Electrical: occupational contact with power lines, faulty appliances and wiring, lightning, and children biting cords. Chemical: acids and alkalis in industry, cleaning and laboratory work, and at home. Alkalis are worse than acids because they keep liquefying tissue and drive deeper.
Clinical Manifestations
Electrical: small entry and exit wounds with devastating damage in between — cardiac dysrhythmias and arrest, respiratory arrest, deep muscle necrosis, fractures and dislocations from tetanic contraction or from the fall, spinal injury, cataracts and later neurological deficits. Dark red or tea-colored urine means myoglobin from destroyed muscle, and it will block the kidneys. Chemical: pain that continues and deepens, with the tissue changing appearance over hours.
Assessment and Diagnostic Findings
Continuous cardiac monitoring for at least 24 hours after any significant electrical injury, plus a 12-lead ECG. Creatine kinase and urine myoglobin; watch urine color and output. Cervical spine and long-bone imaging if there was a fall or tetany. Neurological checks, and a baseline eye examination. For chemical burns, identify the agent, its concentration and the duration of contact — the safety data sheet is part of the assessment.
Medical Management
Electrical: ACLS for the dysrhythmia, aggressive fluids to flush myoglobin, often titrated to a much higher urine output of 75–100 mL/hr, with sodium bicarbonate and mannitol if ordered. Fasciotomy for compartment syndrome. Chemical: brush off dry chemical first, then irrigate with copious running water for 20 minutes or longer — and never try to neutralise a chemical burn; the reaction generates heat and makes it worse. Eye exposure is irrigated continuously.
Nursing Management and Client Education
Make the scene safe before you touch anyone — with electricity, the source is turned off first; with chemicals, you wear protection and the client is decontaminated before entering the department. Remove all contaminated clothing. For an electrical injury, treat it as a possible spinal injury and immobilise until cleared. Watch the urine color every hour and report any darkening. Teach electrical safety at home, and safe chemical storage and eye protection at work. Follow-up matters here: cataracts and neurological problems can appear months after an electrical injury, so teach the client what to watch for and to mention the injury to any clinician who sees them later.
🧠 Mind maps 1
Built from this page's own content — the same four questions every time, so the shape is familiar before the topic is.
🎯 Who gets it
- Thermal — flame, scald, contact. The commonest kind, and scalds dominate in children.
- Chemical — keeps burning until the agent is removed; brush powder off before irrigating.
- Electrical — the visible wound understates the injury; the current damages everything on its path.
- Radiation — sunburn through to radiotherapy injury.
- Highest risk: the very young, the very old, and anyone with impaired mobility or sensation.
👀 What you see
- Superficial — red, dry, blanches, painful.
- Partial thickness — blisters, moist, weeping, and the most painful.
- Full thickness — white, leathery, waxy, dry, and painless: the nerves are gone.
- Inhalation clues: facial burns, singed nasal hair, soot in the mouth, hoarseness, stridor.
- Fluid shift shows as tachycardia and falling urine output long before the blood pressure moves.
🧪 What confirms it
- Rule of nines for the extent — head 9, each arm 9, each leg 18, front torso 18, back 18, perineum 1.
- Children get a pediatric chart: proportionally bigger heads, so percentage shifts from legs to head.
- Carboxyhemoglobin, because pulse oximetry reads normal in carbon monoxide poisoning.
- Serial electrolytes: potassium rises early from cell destruction, then falls during diuresis.
🩺 What you do
- Airway first — intubate early if inhalation is suspected; after the swelling you cannot.
- Parkland: 4 mL × kg × %TBSA of lactated Ringer's over 24 h, half in the first 8 — timed from the burn, not from arrival.
- Titrate to urine output: 30–50 mL/hr adults, 1 mL/kg/hr children.
- Circumferential burns act as a tourniquet as edema builds — watch for the need for escharotomy.
- After 48 hours the risk becomes infection: strict asepsis, and no prophylactic systemic antibiotics.
🎥 Lecture recordings 4
Tap a card to open that recording in Google Drive. The same list lives in the lecture library.
All NUR 258 recordings →🖼️ Infographics & deep dives 7
Every burn page already on this site, in the order you would read them.
📋 Active Learning Template 1
The ATI template layout, filled from this page. Print it, cover the right, rebuild it.
📋 Burns6 parts
🖼️ InfographicsBurns II - Major burns patho, signs & TreatmentsBurns - Types & Care for minor burnsMajor BurnsBurns III - Rule of 9's & RehabilitationBurns - Top Missed Questions
Filled from this page's own content, row by row. No ATI chapter number is given, because that chapter was not opened.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
- A burn destroys skin and, above roughly 20% TBSA, becomes a systemic injury: capillaries leak plasma into the tissue and the client becomes hypovolemic from a wound that has not bled.
- Depth determines healing and pain; extent determines fluid need and survival.
Health Promotion & Disease Prevention
- Water heater below 49 °C / 120 °F; turn pan handles inward; no tablecloths within a toddler's reach.
- Working smoke alarms, a rehearsed exit plan, and no smoking in bed.
- Sun protection, and eye and skin protection for chemical work.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
- Extremes of age, impaired mobility, sensory loss, cognitive impairment, and occupational exposure.
Assessment — Expected Findings
- Superficial: red, dry, blanching, painful.
- Partial thickness: blistered, moist, weeping, most painful.
- Full thickness: white or leathery, dry, painless.
- Hypovolemia: tachycardia, falling urine output, thirst, restlessness.
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
- Potassium rises early from cell lysis, then falls in the diuretic phase.
- Hematocrit rises early from plasma loss — it looks like polycythemia and is really dehydration.
- Carboxyhemoglobin where there was fire in an enclosed space.
Diagnostic Procedures
- Rule of nines or a Lund–Browder chart for extent.
- Bronchoscopy where inhalation injury is suspected.
🩺 What you doNursing Care · Medications
Nursing Care
- Airway, then fluid, then the wound — in that order, every time.
- Parkland formula from the time of the burn; titrate to urine output.
- Keep the client warm: large burns lose heat fast and hypothermia worsens everything.
- Strict asepsis; a burn wound is an open door.
Medications
- Opioids intravenously — intramuscular absorption is unreliable while perfusion is poor.
- Topical antimicrobials to the wound; tetanus prophylaxis.
💬 Around the patientClient Education
Client Education
- Pressure garments and range-of-motion work prevent contractures; both are uncomfortable and both are essential.
- Protect healed skin from the sun for at least a year.
- Itching during healing is expected and is not infection.
⚠️ What goes wrongComplications
Complications
- Airway obstruction from inhalation injury — the reason airway comes first.
- Hypovolemic shock in the first 24–48 hours.
- Infection and sepsis after 48 hours, and the leading cause of death.
- Compartment syndrome under circumferential burns.
- Curling ulcer — stress ulceration of the stomach after major burns.
📝 Notes & key concepts
The lines from this module that carry a number, a dose or an absolute rule — the ones that decide questions. Everything else is on the cards above.
- Face, neck or chest burns → airway is the priority. Assess breathing before you estimate TBSA or start fluids. Waist-down burns → fluids are the priority.
- Airway red flags: singed nasal hair or eyebrows, carbonaceous sputum, hoarseness, stridor, drooling or trouble swallowing, falling SpO2.
- Rule of Nines: head/neck
9, each arm9(4.5 front / 4.5 back), anterior trunk18, posterior trunk18, each leg18, perineum1. Know the sub-fractions — the front of a forearm is ~2.25%, not 4.5%. - Her palm including fingers ≈ 1% TBSA, used for scattered irregular burns.
- Parkland:
4 mL × kg × %TBSAof LR over 24 hr. First half in the first8 hrtimed from the injury, not from arrival; second half over the next16 hr. Count only 2nd- and 3rd-degree burns. - Target urine output
≥30 mL/hrin adults — that is how you know resuscitation is working. - Depth: superficial = red, dry, no blisters. Superficial partial = blisters, moist, very painful. Deep partial = mottled/waxy, less painful. Full-thickness = white/leathery, painless. 4th degree = into muscle or bone.
- Phases: emergent (0–48 hr — airway, fluids, prevent shock), acute (wound care, infection, nutrition, pain), rehabilitative (contractures, scarring, psychosocial).
- Big burns (60–70%): infection, hypothermia, compartment syndrome, and fluid overload after the first 24 hours.
- Rule of nines as they drilled it: head/neck
4.5front +4.5back · each arm9· each leg18· anterior trunk18· posterior trunk18· perineum 1 · palm ≈ 1% for burns that do not fit the nines. - First-degree burns are never counted in TBSA or in Parkland.
- Parkland as taught here:
4 mL × kg × %TBSAover 24 h, half in the first 8 h. Lactated Ringer's, always — they said burn centers are "very sensitive about this." Not NS, not D5W. - Their three worked problems: 63 kg / 58.5% →
921 mL/hr· 75 kg / 54% →1,013 mL/hr· 100 kg / 47% →1,175 mL/hr. - Urine output:
30 mL/hris the floor,50–60is what they want. Below0.5 mL/kg/hr→ increase fluids. Parkland is a starting rate — titrate to output.
🎯 Module quiz
Questions for this module. They also feed the Mega Quiz.
Nothing here yet — drop it in when you have it