Burns: NCLEX Priorities
Rule of nines, Parkland formula, phases of burn care, and why airway comes first.
Burn questions reward a strict order: airway, fluids, then everything else. Know the numbers cold.
Airway first, always
Inhalation injury kills before fluid loss does. Red flags: singed nasal hairs, facial burns, hoarseness, carbonaceous (sooty) sputum, fire in an enclosed space. Edema worsens over hours, so anticipate early intubation before the airway closes. Carbon monoxide: give 100% O2. Pulse oximetry reads falsely normal because it cannot tell carboxyhemoglobin from oxyhemoglobin.
Rule of nines (adult)
Head 9%. Each arm 9%. Each leg 18%. Anterior trunk 18%. Posterior trunk 18%. Perineum 1%. Count only partial- and full-thickness burns toward TBSA. Superficial (sunburn-type) burns do not count.
Parkland formula
4 mL x kg x %TBSA of lactated Ringer's over 24 hours. Give half in the first 8 hours, counted from the time of injury, not arrival. The rest runs over the next 16 hours. Adequacy check: urine output 0.5 mL/kg/hr (about 30 mL/hr in adults). Electrical burns need higher output to flush myoglobin and protect the kidneys.
Phases of burn care
Emergent (first 24-48h): fluid shifts into the interstitium. Expect hyperkalemia (cell lysis) and hyponatremia. Third-spacing, hypovolemia, shock risk. Acute: starts with diuresis as fluid returns to the vessels. Now watch for hypokalemia, infection (the top killer after the first days), wound care, nutrition (high protein, high calorie). Rehabilitative: contracture prevention, pressure garments, ROM, body image.
Circumferential burns
A full-thickness burn wrapped around a limb or the chest acts like a tourniquet as edema builds. Check pulses distally every hour. Chest involvement restricts ventilation. The fix is escharotomy, an incision through the eschar to release pressure.
Frequently asked
Why LR and not NS for burn resuscitation?
Large-volume NS causes hyperchloremic acidosis. LR is the standard resuscitation fluid in Parkland.
Patient burned at 0800, arrives at 1000. When does the first 8-hour window end?
- Parkland counts from time of injury. Two hours are already gone, so the remaining first-half volume runs faster.
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