Guide — Emergency Nursing
Burn Nursing Care Guide
Burn classification, Rule of Nines TBSA estimation, Parkland formula fluid resuscitation, inhalation injury recognition, and wound care priorities for emergency and critical care nursing.
12 min read · Emergency Nursing
Educational use only. Burn care is complex and institution-specific. Major burns require immediate burn center consultation and resuscitation per established protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Initial Burn Assessment Priorities
Primary survey first: Complete ABCDE assessment before focusing on burns. Airway compromise is the most immediate life threat — inhalation injury can cause rapid airway edema.
Inhalation Injury — Recognize Immediately
- Singed nasal hairs, eyebrows, or facial hair
- Carbonaceous (black, sooty) sputum or oropharyngeal deposits
- Hoarseness, stridor, or voice change
- Facial burns + enclosed-space fire history
- Action: immediate high-flow O₂ → anticipate early intubation (edema worsens over hours)
Two large-bore IVs: Establish IV access through unburned skin if possible; intraosseous access if IV access fails. Begin fluid resuscitation immediately for burns ≥ 20% TBSA (pediatrics ≥ 15% TBSA).
Remove clothing and jewelry: Stop the burning process. Chemical burns: brush off dry chemicals first, then flush with water. Electrical burns: ensure scene is safe first.
Foley catheter: Insert for major burns to monitor urine output (goal: 0.5–1 mL/kg/hr adults; 1 mL/kg/hr for children).
Burn Classification
| Depth | Appearance | Sensation | Healing | Nursing Priority |
|---|---|---|---|---|
| Superficial (1st Degree) Epidermis only | Erythema, dry, no blisters | Painful (intact nerve endings) | 3–5 days, no scarring | Cooling with room-temp water, moisturizing lotion, pain management; no debridement needed |
| Superficial Partial-Thickness (2nd Degree Superficial) Epidermis + superficial dermis | Moist, weeping, pink/red, blisters present | Very painful (exposed nerve endings) | 7–21 days, minimal scarring if no infection | Non-adherent dressings (Mepitel, Mepilex), silver-containing dressings; blister management per protocol; pain management critical |
| Deep Partial-Thickness (2nd Degree Deep) Epidermis + deep dermis | Pale/mottled/red, may have blisters, less moist | Reduced sensation (deeper nerve involvement); painful to pressure | 21–35 days, significant scarring likely; may require grafting | Similar to superficial partial-thickness but higher infection and contracture risk; monitor for conversion to full-thickness |
| Full-Thickness (3rd Degree) Epidermis + entire dermis; may involve subcutaneous tissue | Leathery, waxy, white/brown/black; dry; eschar formation | Painless (nerve endings destroyed) — patient may not report pain at burn site | Does NOT heal without grafting (no remaining epithelial cells) | Escharotomy for circumferential burns (impaired perfusion, compartment syndrome); skin grafting required; contracture prevention; infection vigilance |
| Deep Full-Thickness (4th Degree) Extends to muscle, bone, or tendon | Charred, black, deep tissue visible | No pain (complete nerve destruction) | Requires amputation and/or extensive reconstruction | Immediate surgical consultation; amputation often necessary; aggressive infection control |
Rule of Nines — Total Body Surface Area (TBSA)
IMPORTANT: Superficial (1st degree) burns are NOT included in TBSA calculation
| Body Area | Adult | Infant / Child Difference |
|---|---|---|
| Head & Neck | 9% | 18% (larger proportional head) |
| Each Arm (entire) | 9% (upper 4% + lower 5%) | 9% |
| Anterior Trunk | 18% | 18% |
| Posterior Trunk | 18% | 18% |
| Each Leg (entire) | 18% (thigh 9% + lower leg 9%) | 14% (smaller proportional legs) |
| Perineum / Genitalia | 1% | 1% |
| Palm of patient's hand | ~1% (useful for irregular burns) | ~1% |
For irregular burns or children: use the Lund-Browder chart (more accurate for pediatrics).
Parkland Formula — Fluid Resuscitation
Parkland Formula:
4 mL × weight (kg) × % TBSA = Total LR in first 24 hours
First 8 Hours
Give ½ (50%) of total calculated volume
Time starts from TIME OF INJURY, not from hospital arrival
Next 16 Hours
Give remaining ½ (50%) of total calculated volume
Fluid of choice: Lactated Ringer's (LR) — NOT normal saline (saline causes hyperchloremic metabolic acidosis in large volumes)
Titrate to urine output: 0.5–1 mL/kg/hr adults; 1 mL/kg/hr children — Parkland is a starting estimate, not a fixed prescription
Example: 70kg patient with 40% TBSA burns: 4 × 70 × 40 = 11,200 mL LR. Give 5,600 mL in first 8h, then 5,600 mL over next 16h.
Pediatrics: Add maintenance dextrose-containing fluids (LR alone causes hypoglycemia in children). Typical formula adds D5LR maintenance separately.
Burn Center Transfer Criteria
American Burn Association — Transfer to Burn Center
- Partial-thickness burns > 10% TBSA
- Any full-thickness burn
- Burns involving face, hands, feet, genitalia, perineum, or major joints
- Circumferential limb burns (escharotomy risk)
- Electrical burns (including lightning injury)
- Chemical burns
- Inhalation injury
- Burn injury in patients with significant pre-existing medical disorders
- Any burn in pediatric patients (if local facility lacks pediatric capability)
- Burns with concomitant traumatic injury
Special Burn Types
| Burn Type | Key Nursing Considerations |
|---|---|
| Chemical burn | Brush off dry chemical first (water activates some dry agents). Then flush copiously with water for 20–30 min. Alkali burns (lye, bleach) penetrate deeper and longer than acid burns — continue irrigation until pH 7–8 on litmus. Remove contaminated clothing. Eye irrigation for ocular exposure. |
| Electrical burn | Entry and exit wounds small — internal damage is far greater. Cardiac monitoring (dysrhythmia risk). Aggressive hydration to prevent myoglobinuria-induced renal failure (goal UO 1–2 mL/kg/hr or 100 mL/hr). Check CK, urine myoglobin. ECG for dysrhythmias. |
| Circumferential burn | Eschar tightens like a tourniquet as edema develops. Monitor distal pulses q1h with Doppler. Signs of vascular compromise: pallor, pulselessness, paresthesias, paralysis, pain (pain may be absent if nerve damage). Escharotomy performed by provider if pulses absent. |
| Inhalation injury | Three components: (1) Thermal — supraglottic edema; (2) Chemical — tracheobronchitis from toxic gases; (3) Systemic — carbon monoxide (CO) poisoning. CO treatment: 100% O₂ via non-rebreather mask (reduces CO half-life from 4–5h to 60–90 min). CO levels with SpPulse-CO oximetry. Cyanide from synthetic material fires — suspect if profound cardiovascular collapse. |
Nursing Priorities — Major Burns
| Priority | Nursing Action |
|---|---|
| Airway | High-flow O₂; anticipate early intubation for inhalation injury (edema worsens); prepare RSI medications |
| Fluid resuscitation | 2 large-bore IVs; LR per Parkland formula; monitor urine output q1h (goal 0.5–1 mL/kg/hr) |
| Temperature | Burns = massive hypothermia risk (lost skin = lost thermoregulation). Warm IV fluids, warm environment, cover patient between assessments. DO NOT use ice — vasoconstriction worsens tissue injury. |
| Wound care | Cover with dry sterile dressings. Do NOT apply ice, butter, or toothpaste. Silver sulfadiazine or Mepitel/silver dressings per order. Tetanus prophylaxis. |
| Pain management | IV opioids (partial-thickness burns are extremely painful; full-thickness perimeters are painful). Procedural pain management for dressing changes. |
| Infection prevention | Strict aseptic technique for dressing changes. Systemic antibiotics only for documented infection (prophylactic antibiotics increase resistant organisms). Monitor wound appearance daily. |
| Nutrition | Major burns cause extreme hypermetabolism. Early enteral nutrition (within 6–24h). High calorie + high protein requirements. Nutritional support critical to wound healing and immune function. |
NCLEX Pearls
Parkland formula fluid = LR, NOT normal saline. NS causes hyperchloremic metabolic acidosis in large volumes.
Time starts at injury, not admission. If patient arrives 2h post-burn, remaining first-8h fluids compressed into 6h.
Superficial (1st degree) NOT counted in TBSA. Only partial-thickness and full-thickness burns count.
Full-thickness burns are PAINLESS at the burn center (nerve endings destroyed), but painful at the perimeter — patient may report less pain than expected.
Inhalation injury = intubate early. Airway edema progresses over hours — harder to intubate once swelling peaks.
Electrical burns: small external wounds, massive internal damage. Monitor ECG and urine myoglobin.
DO NOT apply ice, butter, or home remedies — worsen tissue damage and cause hypothermia.
Urine output is the best guide to fluid resuscitation adequacy — titrate Parkland rate to UO goal, not a fixed volume.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →