Burns: Classification, Resuscitation, and Nursing Management

Burns are among the most complex injuries in nursing practice, requiring rapid airway assessment, precise fluid resuscitation, infection prevention, and long-term rehabilitation. This guide summarizes the high-yield concepts students need for rapid exam revision.

Definition

Burns are injuries to the skin and underlying tissues caused by heat, chemicals, electricity, or radiation.

Burn Depth Classification

• Superficial (1st degree) — Epidermis only; red, dry, painful, no blisters. Heals in 3–7 days.
• Superficial partial-thickness (2nd degree) — Epidermis and upper dermis; red, moist, blisters, weeping; very painful. Heals in 1–3 weeks.
• Deep partial-thickness (2nd degree) — Epidermis and deep dermis; pale, waxy, less blistering; decreased sensation. Heals in 3–6 weeks.
• Full-thickness (3rd degree) — All skin layers; charred, white, leathery, dry; no pain. Requires skin grafting because no epithelial cells remain.
• 4th degree — Extends to muscle, bone, tendon; charred, black eschar; no sensation. Requires amputation or grafting.

Types of Burns and Inhalation Injury

• Thermal burns are the most common type.
• Chemical burns — Irrigate copiously with water; do not neutralize the chemical.
• Electrical burns — Cause deep tissue damage with small entry/exit wounds. Monitor for cardiac arrhythmias and renal failure from myoglobinuria.
• Inhalation injury is the leading cause of death in burn patients.

Signs of inhalation injury

• Facial burns, singed nasal hairs
• Hoarseness, wheezing, stridor
• Carbonaceous sputum
• Soot around the mouth or nose

The priority is to secure the airway — early intubation is often needed before swelling compromises breathing.

Rule of Nines (Adult)

Method for estimating total body surface area (TBSA) affected:

• Head and neck — 9%
• Each arm — 9% (18% total)
• Anterior trunk — 18%
• Posterior trunk — 18%
• Each leg — 18% (36% total)
• Perineum — 1%

Pediatric adjustments: Head is 18%, each leg is 13.5%.

The patient's palm (including fingers) ≈ 1% TBSA — useful for estimating small or scattered burns.

Fluid Resuscitation: Parkland Formula

Calculates fluid requirements for the first 24 hours after a burn.

• Formula: 4 mL × weight (kg) × %TBSA, using lactated Ringer's solution.
• Give half the total volume in the first 8 hours from the time of burn (not arrival).
• Give the remaining half over the next 16 hours.
• After 24 hours, switch to colloids such as albumin and D5W.

Example: A 70 kg patient with a 40% burn requires 4 × 70 × 40 = 11,200 mL in 24 hours.

Monitoring Resuscitation and Escharotomy

• Urine output is the best indicator of adequate fluid resuscitation.
• Adult target: 0.5–1 mL/kg/hr.
• Pediatric target: 1–1.5 mL/kg/hr.
• Eschar is the hard, leathery dead tissue over full-thickness burns.
• Circumferential burns of the chest or extremities can constrict breathing or blood flow.
• Escharotomy — surgical incision through eschar to relieve pressure and restore circulation.
• Signs of compartment syndrome (5 P's): pain, pallor, paresthesia, paralysis, pulselessness.

Phases of Burn Care

• Resuscitative (Emergent) — first 24–72 hours: Airway management, fluid resuscitation, wound assessment, pain control.
• Acute — days to weeks: Wound care, infection prevention, debridement, grafting, nutrition.
• Rehabilitative — months to years: Scar management, physical and occupational therapy, psychosocial support.

Burn Management

Infection Prevention

• Burn wounds are highly susceptible to infection due to loss of the skin barrier.
• Pseudomonas aeruginosa is a common burn wound pathogen.
• Topical antimicrobials:
  • Silver sulfadiazine — standard burns; do not use on the face.
  • Mafenide acetate — penetrates eschar, but may cause metabolic acidosis.
  • Silver nitrate — less penetration.
• Signs of infection: conversion of partial-thickness to full-thickness, green discoloration, foul odor, fever, leukocytosis.
• Sepsis is the leading cause of death after the initial resuscitation phase.

Pain Management

• Burn pain includes background, procedural, and breakthrough pain.
• Opioids (morphine, hydromorphone, fentanyl) are first-line for severe pain.
• Use preemptive analgesia before dressing changes and debridement.
• Non-pharmacologic options: distraction, guided imagery, music therapy.

Nutrition

• Burn patients are hypermetabolic.
• Caloric goal: 25–30 kcal/kg/day plus additional calories based on burn size.
• Protein: 1.5–2 g/kg/day to support wound healing and prevent muscle wasting.
• Enteral nutrition is preferred over parenteral to maintain gut integrity.
• Supplement vitamins A, C, and zinc to promote tissue repair.

Nursing Assessment and Interventions

• Assess ABCs first; look for signs of inhalation injury.
• Secure the airway immediately if inhalation injury is suspected.
• Remove clothing and jewelry from burned areas (jewelry retains heat).
• Cool the burn with tepid water — do not use ice (causes vasoconstriction and tissue damage).
• Cover with clean, dry sheets to prevent contamination and hypothermia.
• Insert a Foley catheter to monitor urine output and an NG tube for gastric decompression.
• Administer IV fluids per Parkland formula; provide tetanus prophylaxis if needed.

Common Exam Traps

• Parkland formula uses lactated Ringer's, not normal saline.
• The first 8-hour fluid window starts at the time of burn, not hospital arrival.
• Urine output is the best indicator of resuscitation success.
• With inhalation injury, airway first.
• Silver sulfadiazine cannot be used on the face.
• Mafenide acetate penetrates eschar but causes metabolic acidosis.

Key takeaways

• Burn depth ranges from superficial (painful) to full-thickness (painless, requires grafting).
• Rule of Nines (adult): head 9%, each arm 9%, anterior/posterior trunk 18% each, each leg 18%, perineum 1%.
• Parkland formula: 4 mL × kg × %TBSA of lactated Ringer's; half in the first 8 hours from time of burn.
• Urine output (0.5–1 mL/kg/hr in adults) is the gold standard for resuscitation adequacy.
• Airway protection is the top priority with suspected inhalation injury — the leading cause of early death.
• Escharotomy is required for circumferential burns to prevent compartment syndrome; sepsis is the leading cause of late death.