Burns for the Bedside: Assessment, Parkland Formula, and Acute Complications

Burn Basics and Assessment

Heather Murphy: Welcome back, everybody. I’m Heather, and today Caitlin and I are diving into burns, which is one of those high-stress topics that always shows up on exams and in real life.

Caitlin Hope: Yeah, this is my home turf. Burn‑trauma is like organized chaos, but once you know the patterns, it gets a lot less scary. So let’s start with what actually causes burns.

Heather Murphy: In the simplest terms, a burn is an injury to body tissue from heat, cold, chemicals, electrical current, or radiation. The chapter really emphasizes three things that determine how bad that burn will be: the temperature of whatever caused it, how long the person was exposed, and what type of tissue was injured.

Caitlin Hope: And in practice, we usually see three big mechanisms. Thermal burns, which are from flame, flash, scald, or hot objects. Those are the most common. Then chemical burns from acids, alkalis, or organic compounds. And electrical burns, where the injury comes from intense heat generated by the current passing through the body.

Heather Murphy: Exactly. And with electrical burns, the severity depends on the voltage, how resistant the tissue is, the pathway of the current, the surface area that’s in contact, and how long that current flowed. So you may see a tiny entry wound, but there can be major deep damage along that pathway that you cannot see.

Caitlin Hope: Once we know the mechanism, we have to think depth. Traditionally you hear first, second, third, even fourth degree. The American Burn Association groups them more cleanly into partial‑thickness and full‑thickness burns.

Heather Murphy: Right. Partial‑thickness burns involve part of the dermis. Those are extremely painful because nerve endings are still intact. They can re‑epithelialize, so many of them can heal without grafting if managed correctly. Full‑thickness burns destroy all the skin layers, and the nerve endings are gone, so they’re actually initially painless.

Caitlin Hope: That “painless” piece really throws students. Someone with a deep, white, leathery area might tell you that spot doesn’t hurt, while the pink, blistered partial‑thickness areas are screaming. And those full‑thickness areas usually need surgical debridement and skin grafting to heal.

Heather Murphy: Now, from an NCLEX lens, as soon as you walk up to a burn patient, you’re thinking airway, breathing, circulation. Always. Airway is particularly urgent if the burn is on the face or neck, or if there are signs of inhalation injury—like soot, singed nasal hair, or a history of being in an enclosed fire. Those patients are at high risk for upper airway edema and obstruction.

Caitlin Hope: Yeah, and circumferential burns around the chest can mechanically limit chest expansion too, because of that tight, leathery eschar. So for exam questions: face, neck, or circumferential chest burns should make you think “airway first, potential early intubation.”

Heather Murphy: Once you’re sure the airway and breathing are addressed and you’ve started circulation support, then we classify the burns. Two major pieces: depth, which we already talked about, and extent—how much total body surface area, or TBSA, is burned.

Caitlin Hope: In adults, you’ll see the Rule of Nines a lot. It’s a quick bedside tool to estimate TBSA by assigning each major body region a percentage that’s a multiple of nine. Let’s talk through it using the classic adult diagram you see on the slide. We’re estimating the percent of total body surface area burned by looking at body regions: The head and neck together count as 9% of TBSA total. Think of it as 4.5% for the front of the head and neck and 4.5% for the back. Each arm is 9% total. That’s 4.5% for the anterior, or front, of the arm and 4.5% for the posterior, or back, of that same arm. The entire anterior trunk – chest plus abdomen – is 18%. The entire posterior trunk – upper back and lower back together – is also 18%. Each leg is 18% total, which is 9% for the front of the leg and 9% for the back. And finally, the genital or perineal area is a small but important region, and it counts as 1%. In practice, when you’re estimating burns in an adult, you mentally add these regions together. For example, if a patient has burns on the entire front of one leg and the entire front of their trunk, that’s 9% for the front of the leg plus 18% for the chest and abdomen front, for a total of 27% TBSA. And remember, for both exams and real life, we only count partial‑thickness and full‑thickness burns in that total, not superficial sunburn‑type redness.

Caitlin Hope: Location also matters hugely for severity. Burns to the face and neck threaten respiratory function. Hands, feet, and eyes affect self‑care and long‑term function. The perineal area has a high infection risk. And circumferential burns of an extremity can compromise circulation distal to the burn and might need an escharotomy or even a fasciotomy.

Heather Murphy: And one last plug before we move on: we’re not just treating burns, we’re also burn‑prevention advocates. Things like smoke alarms, child‑resistant lighters, good building codes, and community education really matter. But when burns do happen, everything starts with that airway assessment and then a systematic classification of the injury.

Emergent Phase Priorities – Airway and Fluids

Caitlin Hope: Let’s move into what happens in those first hours—the emergent, or resuscitative, phase. The chapter defines this as the period where we’re dealing with immediate, life‑threatening problems. It usually lasts about 48 to 72 hours from the time of the burn.

Heather Murphy: And if you remember one biggest threat in this phase, it’s hypovolemic shock from massive fluid shifts and edema formation. Capillaries become leaky, fluid moves out of the vascular space, and blood pressure can drop while the tissues swell.

Caitlin Hope: At the scene, priorities are super basic but critical: remove the person from the source and stop the burning process. Then, if the patient is responsive, immediately assess and monitor airway, breathing, circulation.

Heather Murphy: For thermal burns, you’d remove burned clothing and cover the burns with a clean, cool, tap‑water–dampened towel—not ice. For chemical burns, remove any dry chemical particles from the skin and flush with copious amounts of water. The idea is to stop the ongoing tissue damage.

Caitlin Hope: Once they hit the ED or burn unit, we go right back to ABCs. Airway management is first, especially with facial burns or suspected inhalation. Then we focus on circulation—this is where fluid therapy really comes in.

Caitlin Hope: Fluid resuscitation formulas give you a starting total for the first 24 hours from the time of injury, and we typically front‑load more of that volume in the first part of the resuscitation and then taper over the rest of the period.

Heather Murphy: The most common starting point is the Parkland Formula. It says: give 4 milliliters of Lactated Ringer’s per kilogram of body weight per percent of total body surface area burned—so 4 mL times the patient’s weight in kilograms, times the percent TBSA burned. That gives you the total fluid for the first 24 hours from the time of injury.

Caitlin Hope: Let’s walk through a quick example so you can hear the math. Say you have a 70‑kilogram adult with 30% TBSA partial‑ and full‑thickness burns. You’d calculate 4 mL × 70 kg × 30, which equals 8,400 mL of Lactated Ringer’s over the first 24 hours. Half of that total—4,200 mL—should be given in the first 8 hours because we need to "super-hydrate" this patient. The remaining 4,200 mL is spread over the next 16 hours. If you like it broken into hourly rates, that’s about 525 mL per hour for the first 8 hours, then about 260 mL per hour for the next 16 hours, and then you adjust those rates based on how the patient is actually responding.

Heather Murphy: Some key signs to determine if the patient is responding well to the fluid resuscitation include stable blood pressure, improved level of consciousness, and adequate urine output. All of these improvements are indications of an improved fluid volume status.

Caitlin Hope: Exactly. So in terms of nursing priorities in this phase, the chapter highlights: rapid ABC assessment, airway management, fluid therapy, and initial wound care. We’re giving IV analgesics—usually opioids—because even in that chaotic early window, pain is intense for partial‑thickness burns.

Heather Murphy: We also can’t forget early nutrition. The text points out that early, aggressive nutritional support decreases mortality and complications, optimizes healing, and reduces the negative effects of hypermetabolism and catabolism. So, even though it feels “early,” we’re already thinking calories and protein.

Caitlin Hope: Venous thromboembolism prophylaxis is another piece. If it’s not contraindicated, it should be started early, because these patients are often immobile and hypercoagulable. Blood clots are not a problem we want to add to this already complicated issue.

Heather Murphy: And through all of this, we’re keeping an eye on the respiratory system. Even if the airway looked okay initially, edema can build. So any change in voice, stridor, increased work of breathing—those are escalation moments where we need the provider at the bedside and possibly respiratory or anesthesia.

Caitlin Hope: So, to summarize this phase: stop the burn, secure the airway, start appropriate fluids guided by formulas and clinical response, control pain, begin wound coverage to help prevent infection, and start thinking about nutrition and VTE prophylaxis. It’s a lot, but it all anchors back to ABCs and preventing hypovolemic shock.

Acute Phase – Wound Care, Electrolytes, and Psychosocial Needs

Heather Murphy: Once we get through that emergent window and fluid shifts start to stabilize, we move into the acute phase. The chapter defines this as beginning with mobilization of extracellular fluid and diuresis, and it ends when burn wounds are nearly healed or covered with skin grafts. That can be weeks to many months.

Caitlin Hope: Clinically, you see wound care really take center stage in this phase. Partial‑thickness wounds will form eschar that starts separating fairly soon after injury. Once it’s removed, you’ll see red or pink scar tissue as re‑epithelialization kicks in.

Heather Murphy: Full‑thickness eschar, especially at the margins, takes longer to separate and usually needs surgical debridement and skin grafting. The standard now is early removal of necrotic tissue followed by split‑thickness autograft skin. After that, the goal is rapid, moist wound healing, preventing infection, and managing pain at the graft and donor sites.

Caitlin Hope: Wound care in this phase is not just “change the dressing.” It includes observation, assessment, cleansing, debridement, and re‑dressing as ordered. Every dressing change is a chance either to catch an early infection or, if we’re not careful, to introduce one.

Heather Murphy: And the GI system isn’t off the hook. Paralytic ileus can develop if the patient becomes septic, so we’re monitoring bowel sounds, abdominal distention, nausea, that whole picture.

Caitlin Hope: Electrolyte balance is a big nursing focus here. The body is trying to reestablish fluid and electrolyte equilibrium, so we follow serum electrolytes closely, especially sodium and potassium. That means staying on top of lab trends and matching them to what you see in the patient’s neuro status, cardiac rhythm, and muscle function.

Heather Murphy: Pain in this phase has two distinct flavors, and I love how the chapter separates them. There’s the continuous, background pain that just exists around the clock. Then there’s treatment‑induced pain—during dressing changes, ambulation, or rehab exercises. Drugs are first‑line. For treatment‑induced pain, we premedicate with an analgesic and often an anxiolytic, IV or oral, before we start. And then we add nondrug strategies—things like relaxation recordings, guided imagery, computer gaming, hypnosis, or biofeedback—as adjuncts.

Caitlin Hope: And while all this is happening, physical and occupational therapy have to be aggressive. The chapter is really clear: intensive PT throughout recovery is imperative to maintain joint function. Range‑of‑motion exercises during wound care can help reduce skin and joint contractures.

Heather Murphy: Nutrition is still key—adequate calories and protein are needed to support all that healing. And this is where the psychosocial side really ramps up. Patients may become agitated, withdrawn, or combative. They’re dealing with fear, anxiety, anger, guilt, depression—sometimes all of the above.

Caitlin Hope: Yeah, burn survivors can have guilt about the incident, relive the experience, fear death, or struggle with body image, especially if the face or hands are involved. They worry about future surgeries, ongoing discomfort, wound breakdown, and whether life will ever feel “normal” again. Families and caregivers can share all those emotions, too.

Heather Murphy: Older adults are particularly vulnerable. The chapter mentions that once injured, they have more complications in the emergent and acute phases because of preexisting comorbidities and normal age‑related skin changes. So our prevention efforts and our emotional support for them and their caregivers are both crucial.

Caitlin Hope: And we can’t forget the nurses in this picture. Caring for burn patients can be emotionally rewarding but also really draining. You’re dealing with deformities, strong odors, very unpleasant wounds, and you’re the one performing painful treatments day after day.

Heather Murphy: The chapter encourages ongoing support for staff—peer support, self‑care, stress debriefings—to keep a healthy work–life balance. That’s not just “nice to have.” It’s what lets us keep showing up for patients over the long haul.

Caitlin Hope: And there’s a hopeful side, too. Many burn survivors experience posttraumatic growth—positive life changes that come out of surviving something this intense. Our role is to walk with them through the hard parts, advocate for what they need, and connect them with resources like mental health professionals and support groups.

Heather Murphy: All right, we’re going to wrap it there for today. We’ve gone from initial burn mechanisms and assessment through emergent resuscitation and into the long, complex acute phase.

Heather Murphy: Thank you all for listening. Caitlin, always a pleasure hearing about your expertise in this area.

Caitlin Hope: Same here, Heather. Take care everyone, and we’ll see you next time.