The burn patient is leaking their circulating volume into their own tissues. Your job in the first 24 hours is to keep the airway open, put the volume back faster than it leaks, and not let the wound convert or get infected. The #1 intervention in the first 24 hours is IV Lactated Ringer's — and you judge whether it is working by the urine output, not by the number in the bag.
NG-107 = the WHY. Capillary leak, burn shock, the three phases, inhalation injury mechanism, why each lab moves.
NG-123 (this page) = the WHAT-YOU-DO. Priorities in order, the actual fluid orders and how to titrate them, wound care, escharotomy, infection prevention, pain and nutrition. Assume you already know the patho.
🫁 Airway first, alwaysBefore TBSA, before fluids, before pain meds. Enclosed-space fire + hoarseness = anticipate intubation.
💧 LR is the #1 fluidIV Lactated Ringer's in the first 24 h (0.9% NaCl is the alternative). Two large-bore IVs.
🚽 Urine is the report card≥ 30 mL/hr · BP ≥ 90 systolic · HR < 120. Low urine → increase the LR.
💉 IV route ONLYPerfusion is terrible — no IM or SubQ pain meds. They pool, then dump when perfusion returns.
🚑
THE FIRST TEN MINUTES
STEP 1 · IN THIS ORDER
Burns look dramatic. Do not be pulled to the wound. Work the airway, then the volume, then the skin.
🕙 The first-hour roadmap
EXAM TIP When a question gives you a burn patient and four "correct-sounding" actions, the answer is whichever one is closest to the airway.
🧠 “Air, Off, IV, Pee, Warm, Weigh, Numb.” Seven words in order. If you can chant it, you can answer the priority question.
🚨 Remove every ring, watch and bracelet — now
Answer first: the limb is about to swell for the next 24 hours. Jewelry becomes a tourniquet.
Rings, watches, bracelets, belts, piercings — off early, before edema makes it impossible
Remove non-adherent clothing; do NOT peel off clothing that is stuck to the burn — cut around it
Remove synthetic fabric that has melted onto skin only under direction — it can take the skin with it
Check distal pulses, color, capillary refill and sensation in every burned extremity, and keep rechecking
Elevate burned extremities above heart level to limit edema
🧠 “Rings off before the fingers swell.” It takes ten seconds now and an amputation later.
🌡️ Keep them WARM — this is treatment, not comfort
The skin is the body's heat blanket, and a big burn has thrown it away. Burn patients become hypothermic astonishingly fast, and hypothermia worsens acidosis, coagulopathy and the zone of stasis.
Cover with a dry, clean/sterile sheet or blanket during transport
Never apply ice or soak a large burn in cold water — it deepens the burn and drops the core temperature
Raise the room temperature; use warming lights/blankets and warmed IV fluids where available
Limit the time the wound is exposed during dressing changes
Monitor temperature — in the acute phase, hypothermia can be a sign of sepsis, not just heat loss
🧠 Cool the burn (small, first aid) — but warm the PATIENT (large, hospital). That is the line students cross most often.
💧
FLUID RESUSCITATION
STEP 2 · THE #1 INTERVENTION
The bag choice is easy. The skill is titration — reading the patient and changing the rate.
💧 The bag: Lactated Ringer's first
Answer first: IV Lactated Ringer's (LR) is the #1 intervention in the first 24 hours. 0.9% sodium chloride (normal saline) is the other isotonic crystalloid you will see ordered.
Why LR? It is an isotonic crystalloid whose electrolyte make-up is closest to plasma. It replaces the sodium that is being lost into the interstitium and out of the wound, and its lactate is converted to bicarbonate, which helps with the metabolic acidosis of shock.
Give through two large-bore IVs; central access is common in large burns
Place the line through unburned skin where possible — but a burned site is acceptable if it is the only option
Colloids (e.g. albumin) are typically held for the first ~24 h in many protocols, because while capillaries are leaky the protein just follows the water into the tissue
Blood products are given for bleeding/anemia, not as first-line resuscitation
Warmed fluids where available — cold fluid worsens hypothermia
🧠 “LR = Leaky vessels get Ringer's.” Big burn, first day, isotonic crystalloid.
⭐ The three numbers that tell you the fluids are working
Source-standard assessment of fluid resuscitation — memorize these three and their directions.
🧠 “90 · 30 · 120.” BP at least 90, urine at least 30, pulse under 120. Three numbers cover most burn resuscitation questions.
🚽 Hourly urine — how to actually titrate
The classic exam item: "12 hours after a 20% TBSA burn, BP 90/50, pulse 110, urine 20 mL in the last hour. What does the nurse anticipate?" → Increasing the IV Lactated Ringer's.
Also chart: hourly I&O, daily weight (same scale, same time), vital signs frequently, mental status, and the color of the urine. Dark red-brown urine after a deep or electrical burn suggests myoglobin — report it, expect higher fluid targets.
🧠 “The kidney is the cheapest cardiac-output monitor in the room.” If the kidney is making urine, the vital organs are being perfused.
🚨 Over-resuscitation is also harmful
More is not better. Excess fluid ("fluid creep") causes:
This is exactly why the formula is a starting point and the urine output is the steering wheel.
🧠 “Titrate, don't dump.” The formula gets the infusion started; the patient decides where it ends up.
🧾 The formula in one line (details on NG-146)
The commonly taught consensus/Parkland version:
4 mL × kg body weight × %TBSA= total LR for the FIRST 24 h
Half in the first 8 hours, the remaining half over the next 16 hours
The clock starts at the time of injury, not the time of arrival
Only partial- and full-thickness burn is counted in TBSA — superficial (1°) is excluded
The number is a starting estimate. Titrate to urine output, then reassess.
🧠 “4 · weight · burn — half in 8.” Full worked examples on NG-146 and NG-177.
🩹
WOUND CARE, ESCHAROTOMY & GRAFTS
STEP 3 · THE SKIN ITSELF
Two jobs: get the dead tissue off, and get living skin back on before infection wins.
✂️ Escharotomy — cutting the cast off
Answer first: full-thickness eschar is leathery and cannot stretch. When the limb or chest swells underneath it, the eschar acts like a tourniquet. An escharotomy is a lengthwise incision through the eschar to release the pressure.
Where the cuts actually go. The lines follow fixed anatomical courses — the anterior axillary line down each side of the chest, joined top and bottom by transverse cuts, and the mid-medial and mid-lateral lines down each limb — so the release runs the full length of the constricting eschar.
Circumferential limb burn → check pulses (Doppler), capillary refill, sensation and movement hourly. Loss of any = report immediately.
Circumferential chest/abdomen burn → the patient literally cannot expand the chest. Watch for rising respiratory rate, shallow breathing, poor chest excursion and rising ventilator pressures.
Escharotomy cuts through dead eschar only — it is done at the bedside and the eschar itself has no sensation. A fasciotomy goes deeper, through fascia, when muscle compartments are involved (common in electrical burns).
Elevate the limb and keep rechecking after the procedure; expect some bleeding.
🧠 “Eschar = a cast you didn't order.” When a limb swells inside a cast, you split the cast. Same logic, same urgency.
🧴 Wound care — debride, cover, protect
Sequence for a major burn wound, and the two dressing philosophies.
Wrap fingers and toes individually — digits dressed together heal fused together (webbing contracture)
Dressings are changed with sterile technique; hydrotherapy sessions are kept short (heat and sodium loss)
Common topical agents include silver sulfadiazine (avoid in sulfa allergy; can cause leukopenia), mafenide acetate (penetrates eschar well, stings, can cause metabolic acidosis) and silver-impregnated dressings. Never apply a topical agent that has not been prescribed.
Early excision and grafting of full-thickness burns is the modern standard — the sooner dead tissue is off, the lower the sepsis risk
🧠 “Clean → Cut away → Cream → Cover.” Four C's, in that order, with pain medicine given before the first C.
🧬 Skin grafts — donor site, graft site, and what you must protect
Full-thickness burns cannot re-epithelialise: everything that would regrow the skin was destroyed. They need grafting.
🧠 “A graft is a seed, not a bandage.” It has to grow roots (capillaries). Move it in the first few days and the roots tear — the graft dies.
🛡️
INFECTION PREVENTION
STEP 4 · THE ACUTE-PHASE KILLER
Once the fluid crisis is over, sepsis becomes the leading cause of death. The burn wound is a wide-open door with no skin on it.
🌸 The NCLEX classic — no fresh flowers or plants in the room
KAPLAN-STYLE"A client with burns is immunocompromised. What precaution prevents infection?" → Avoid placing fresh flowers or plants in or near the client's room. Standing water and soil harbor Pseudomonas and Aspergillus.
🧠 “No flowers for the burn patient.” It feels unkind, which is exactly why it is a favorite exam answer. Standing vase water is a Pseudomonas soup and potting soil grows Aspergillus.
🚨 Recognizing burn wound sepsis
Do not wait for a positive culture. Watch the trend.
Wound changes — new green/blue-green or foul drainage, color change, edema at the edge, rapid separation of eschar, a partial-thickness wound suddenly converting to full-thickness
Temperature instability — fever or hypothermia. In burns, a falling temperature is just as alarming.
Change in level of consciousness / new confusion — often the earliest systemic sign
Return of paralytic ileus after bowel sounds had come back
WBC very high or very low; rising blood glucose; falling platelets
🧠 “Cold, confused and sugary.” A burn patient who drops their temperature, gets confused and spikes their glucose is septic until proven otherwise.
✅ The infection-prevention checklist
Hand hygiene before and after every contact — the single most effective measure
Private room; gown, gloves, mask and cap for wound care per policy
Sterile technique for dressing changes and all invasive lines
Dedicated equipment; clean/disinfect anything shared between patients
No fresh flowers, no potted plants, no standing water
Screen visitors and staff for infections; restrict anyone unwell
Tetanus prophylaxis on admission per history
Monitor temperature, WBC and wound appearance every shift; culture as prescribed
Remove invasive lines as soon as they are no longer needed
Prophylactic systemic antibiotics are NOT routine — they select for resistant organisms. Antibiotics treat documented infection.
🧠 “Skin is the immune system's front door — and it burned down.” Everything you do is a substitute door.
💊
PAIN, NUTRITION & THE REST
STEP 5 · KEEP THEM ALIVE AND FED
Two under-rated, heavily tested areas: the route you give pain medicine, and when you start feeding.
💉 Pain control — IV route only in the emergent phase
Answer first: give analgesia IV, never IM or subcutaneous. Perfusion to muscle and fat is terrible during burn shock, so an IM dose sits there un-absorbed — and then dumps into the circulation all at once when perfusion is restored, risking overdose.
Premedicate before dressing changes, hydrotherapy, debridement and physiotherapy — procedural pain is the worst pain the patient has
IV opioids (e.g. morphine, fentanyl) titrated to effect are standard; patient-controlled analgesia is common once the patient is stable. Never guess a dose — follow the prescription.
Assess pain with a scale before and after; monitor respiratory rate and sedation level
Add non-pharmacological measures: positioning, warmth, distraction, music, relaxation, cool ambient air on non-burned areas
Remember: a full-thickness area is numb, but the partial-thickness edges around it are excruciating — "no pain in the middle" does not mean "no pain"
Anxiety amplifies pain; itching later in healing is its own problem (see NG-164)
🧠 “IV or nothing.” If an answer choice says administer the opioid intramuscularly to a fresh major-burn patient, it is wrong every single time.
🍗 Nutrition — start enteral feeding once bowel sounds return
Answer first: administer enteral feedings once bowel sounds return. The gut goes quiet from shock (paralytic ileus); the moment it wakes up, feed it. Using the gut also protects the gut mucosa and reduces bacterial translocation.
🧠 “Sounds → spoons.” No bowel sounds = no feeding. Bowel sounds back = start the tube feed. And feed it early — a starved burn patient does not heal.
⛔ The never-do list for a major burn
Never apply ice or immerse a large burn in cold water — deepens the injury and causes hypothermia
Never put butter, oils, ointments or home remedies on a burn
Never break or debride blisters at the bedside without an order — an intact blister is a sterile biological dressing
Never give IM or SubQ analgesia in the emergent phase
Never slow the fluids because the patient looks puffy — titrate to urine output, BP and HR
Never wrap fingers or toes together
Avoid taking BP or starting an IV in a grafted limb; avoid burned skin for cuffs where an alternative exists
Do not delay removing rings and constricting items
Do not apply a topical agent that has not been prescribed
🧠 “Ice, butter, blisters, IM.” Four classic wrong answers. If one appears in the options, it is almost certainly the distractor — unless the question asks what NOT to do.
🦵 Start rehab on day one
Contracture prevention does not wait for the rehab phase — it starts while the patient is still on the ventilator.
Position in anti-deformity alignment from admission (neck extended, shoulders abducted, elbows/knees extended, ankles neutral)
No pillow under the head for anterior neck burns — it flexes the neck into a contracture
Splints as prescribed; range-of-motion exercises daily unless a fresh graft says otherwise
Elevate burned extremities; encourage early ambulation
🧠 “The contracture you prevent on day 1 is the surgery you avoid in year 1.”
🧾 Don't forget these
Tetanus prophylaxis — a burn is a contaminated wound
Stress-ulcer prophylaxis — Curling ulcer risk; watch for coffee-ground NG output
VTE prophylaxis per protocol — these patients are immobile and inflamed
Eye care for facial burns — early ophthalmology input before the lids swell shut
Psychosocial — the patient may have lost their home, their face or a family member. Expect grief, nightmares, acute stress; involve social work and chaplaincy early
Consent & reporting — burns with an inconsistent history in a child or older adult require a safeguarding referral
🧠 “Tetanus, tummy, clots, eyes, mind.” Five easy marks people forget because they are still thinking about fluids.
⚡
QUICK RECALL
SAY IT OUT LOUD
🫁 Airway → fluids → woundPriorities never change. Airway outranks the burn.
💧 LR, two large-bore IVs#1 intervention in the first 24 h.
🚽 Urine <30 → increase LRPlus BP ≥90 and HR <120.
🌸 No flowers · IV pain meds · feed when bowel sounds returnThe three most-tested one-liners.
🎯 Cover & check — 8 rapid-fire questions
Q1: What is the #1 intervention in the first 24 hours of a major burn?
IV Lactated Ringer's solution through large-bore access. 0.9% sodium chloride is the other isotonic crystalloid used. Airway management comes before it in priority order, but LR is the #1 treatment of the burn shock itself.
Q2: Twelve hours after a 20% TBSA burn: BP 90/50, pulse 110, urine 20 mL in the last hour. What do you anticipate?
Increasing the IV Lactated Ringer's. Urine output under 30 mL/hr with a borderline BP and rising pulse means under-resuscitation. Do not slow the fluid, and do not give a diuretic.
Q3: Name the three assessment targets for fluid resuscitation.
Urine output 30 mL/hr or more; systolic blood pressure 90 or more; heart rate less than 120/min.
Q4: A client with circumferential burns to the arm has a cold, numb hand with no palpable pulse. What is happening and what is done?
Rigid eschar plus swelling is compressing the limb — compartment/circulatory compromise. Report immediately; an escharotomy (lengthwise incision through the eschar) is done to relieve the pressure. Elevate the limb and keep reassessing pulses, color, sensation and movement.
Q5: A burn client is immunocompromised. What precaution prevents infection?
Avoid placing fresh flowers or plants in or near the client's room — vase water and soil harbor Pseudomonas and Aspergillus. Add strict hand hygiene, a private room, PPE and sterile technique for dressing changes.
Q6: Why must analgesia be given IV rather than IM in the emergent phase?
Peripheral perfusion is poor, so IM/SubQ drug is not absorbed reliably. It pools in the tissue and can then be absorbed all at once when perfusion is restored, causing an unintended overdose. IV gives predictable onset and can be titrated.
Q7: When are enteral feedings started?
Once bowel sounds return. Burn shock causes paralytic ileus, so the patient is initially NPO, often with an NG tube for decompression. Feeding early once the gut works supports the hypermetabolic state and protects the gut mucosa.
Q8: The burn patient's temperature drops to 35.4 °C and they become confused on day 6. What are you thinking?
Sepsis. In the acute phase, hypothermia and a change in level of consciousness are classic systemic signs of burn wound sepsis — alongside glucose elevation, ileus returning and a WBC that is either very high or very low. Escalate immediately.
📚 Where to go next
NG-107 — Major burns: pathophysiology — the capillary leak, burn shock, phases, inhalation injury and the lab shifts behind everything on this page.