Burns Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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This article was created with AI assistance.
Burn depth classification, TBSA estimation, Parkland formula fluid resuscitation, inhalation injury, wound care principles, and critical nursing management in burn patients.
1. Burn Depth Classification
| Depth | Layers | Appearance | Sensation | Healing | Examples |
|---|
| Superficial (1st degree) | Epidermis only | Red, dry, no blisters | Painful | 3–7 days spontaneously | Sunburn |
| Superficial Partial-Thickness (2nd degree) | Epidermis + superficial dermis | Red, moist, blistered, shiny | Extremely painful (intact nerve endings) | 7–21 days with wound care | Scald from hot liquid |
| Deep Partial-Thickness (2nd degree) | Epidermis + deep dermis | Pale, mottled, may be moist or dry; blisters may rupture | Decreased sensation (damaged nerves) | 3+ weeks; may require grafting | Hot grease, flame contact |
| Full-Thickness (3rd degree) | Epidermis + entire dermis | Leathery, waxy white/tan/brown/black; dry; no blisters | PAINLESS — nerve endings destroyed | Cannot heal without skin grafting | Prolonged flame, chemical, electrical |
| 4th degree | Through all skin + fat, muscle, bone | Charred; bone/tendon exposed | Painless | Amputation often necessary | Prolonged electrical, immolation |
Eschar: Dead, leathery, non-viable tissue that forms over full-thickness burns. Circumferential eschar = compartment syndrome risk. Escharotomy (incision through eschar) may be needed for circumferential burns of extremities or chest (to allow expansion for ventilation).
2. Total Body Surface Area (TBSA) Estimation
Rule of Nines (Adults)
| Body Region | TBSA % |
|---|
| Head and neck | 9% |
| Each arm (entire) | 9% each |
| Chest (anterior trunk) | 18% total: anterior chest 9% + abdomen 9% |
| Back (posterior trunk) | 18% total: upper back 9% + lower back/buttocks 9% |
| Each leg (entire) | 18% each (anterior 9% + posterior 9%) |
| Perineum/genitalia | 1% |
| TOTAL | 100% |
Lund-Browder chart is more accurate for children (head is larger, legs are smaller proportionally). For small irregular burns, use the patient's palm = approximately 1% TBSA.
Only include partial-thickness and full-thickness burns in TBSA calculation — superficial (1st degree) burns are NOT counted for fluid resuscitation decisions.
3. Parkland Formula — Fluid Resuscitation
Parkland Formula:
Total Fluid =
4 mL × kg body weight × % TBSA burned (partial + full thickness only)
Use Lactated Ringer's (not NS) — normal saline causes hyperchloremic metabolic acidosis at large volumes
Timing:
- First 1/2 of total in the first 8 hours from TIME OF INJURY (not from hospital arrival)
- Second 1/2 over the next 16 hours
Example: 70 kg patient with 40% TBSA burn
Total = 4 × 70 × 40 = 11,200 mL (11.2 L)
First 8 hr: 5,600 mL (720 mL/hr)
Next 16 hr: 5,600 mL (350 mL/hr)
Goal urine output: 0.5–1 mL/kg/hr in adults; 1 mL/kg/hr in children — best indicator of adequate resuscitation
4. Inhalation Injury
Inhalation injury = major cause of burn-related mortality. Suspect when:
- Burns in enclosed space (building fire)
- Singed nasal/facial hair
- Sooty sputum or oropharyngeal carbonaceous deposits
- Hoarseness, stridor, barky cough (laryngeal edema forming)
- Edema of lips, tongue, uvula, oropharynx
Act fast: Airway edema progresses — EARLY intubation if any signs of upper airway involvement. Once stridor develops, intubation may be impossible without surgical airway.
Carbon Monoxide (CO) Poisoning
| COHb Level | Symptoms |
|---|
| 10–20% | Headache, nausea — cherry-red skin (sometimes), often misread as "hangover" |
| 20–40% | Confusion, disorientation, weakness |
| 40–60% | Coma, seizures, cardiovascular instability |
| >60% | Death |
CO treatment: 100% oxygen via non-rebreather mask (reduces CO half-life from ~5 hr to ~60 min). Pulse oximetry is UNRELIABLE — SpO2 falsely reads normal because oximeter cannot differentiate oxyhemoglobin from carboxyhemoglobin. Get CO-oximetry (ABG) for true SpO2. Hyperbaric oxygen for severe CO poisoning (COHb >25%, loss of consciousness, cardiac involvement).
5. Burn Zones (Jackson's Burn Model)
| Zone | Description | Outcome |
|---|
| Zone of Coagulation (center) | Point of maximal injury; protein denaturated; cells non-viable | Irreversible necrosis |
| Zone of Stasis (middle) | Decreased perfusion; cells marginally viable | Can be SAVED with adequate resuscitation; lost with inadequate fluids, infection, or pressure |
| Zone of Hyperemia (outer) | Peripheral vasodilation; inflammatory response | Recovers fully |
6. Burn Wound Care
- Cooling: Cool (NOT ice) running water for 10–20 minutes if <20 min from injury; stops burn progression. Do NOT apply ice — causes vasoconstriction and worsens injury. Do NOT apply butter, toothpaste, or home remedies.
- Wound cleaning: Gentle cleansing with mild soap/water or chlorhexidine; remove loose necrotic tissue; be gentle on Zone of Stasis tissue
- Blisters: Leave intact if small (natural barrier); debride if very large, tense, or already broken
- Topical antimicrobials:
- Silver sulfadiazine (Silvadene): broad-spectrum; do NOT use in sulfa allergy, pregnancy, infants <2 months, G6PD deficiency
- Mafenide acetate (Sulfamylon): penetrates eschar (preferred for full-thickness); inhibits carbonic anhydrase → metabolic acidosis
- Bacitracin/Neosporin: for superficial burns and face
- Silver-containing dressings (Mepilex Ag, Aquacel Ag): newer standard; fewer dressing changes, less pain
- Skin grafting: Split-thickness skin graft (STSG) required for full-thickness and deep partial-thickness burns >3 cm; donor site covered with non-adherent dressing (painful)
7. Burn Complications
| Complication | Onset | Assessment/Prevention |
|---|
| Curling's ulcer (stress ulcer) | First 72 hr | Stress ulcer prophylaxis: PPI or H2-blocker in ALL major burn patients; early enteral nutrition |
| Infection/Sepsis | Day 3–5 onward | No prophylactic antibiotics; treat only when culture-positive or clinical sepsis; silver topicals reduce colonization |
| Hypovolemic shock | First 48–72 hr | Parkland formula; monitor UO 0.5–1 mL/kg/hr; avoid over-resuscitation (abdominal compartment syndrome) |
| Inhalation injury/pneumonia | Ongoing | Aggressive pulmonary toilet, HOB 30–45°, early intubation if indicated |
| Contractures/scarring | Healing phase | Early mobilization, splinting, pressure garments for 12–24 months |
| Hypothermia | Ongoing | Loss of skin thermoregulation; warm room, warm fluids, heat lamps |
| Hypermetabolism | Post-burn days | Caloric needs 2× normal; early enteral nutrition; high-protein diet |
NCLEX High-Yield: Burns
- Rule of Nines: Head=9%, each arm=9%, chest=18%, back=18%, each leg=18%, perineum=1%
- Parkland formula: 4 mL × kg × % TBSA; use Lactated Ringer's
- Give ½ first, then ½ of total in first 8 hr; start from time of injury, not arrival
- Goal UO: 0.5–1 mL/kg/hr = best fluid adequacy indicator
- Full-thickness: dry, leathery, painless (nerve endings destroyed)
- CO poisoning: pulse ox is unreliable; treat with 100% O2 via NRB
- Curling's ulcer prophylaxis: PPI or H2-blocker in all major burns
- Silver sulfadiazine: avoid in sulfa allergy, pregnancy, infants <2 months, G6PD
- Cooling a burn: cool running water (NOT ice) for 10–20 min
- Circumferential burn → escharotomy for compartment syndrome
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