Burn depth
Depth determines pain, healing, and the need for grafting.
Estimating size and fluids
Only partial- and full-thickness burns count toward %TBSA.
| Area (adult) | % TBSA |
|---|---|
| Head and neck | 9% |
| Each arm | 9% |
| Front of trunk | 18% |
| Back of trunk | 18% |
| Each leg | 18% |
| Perineum | 1% |
Children have proportionally larger heads, so burn centers use age-adjusted charts (such as Lund-Browder). For small or scattered burns, the client's palm is about 1% TBSA.
An 80-kg adult has partial- and full-thickness burns to the front of the trunk and the entire right arm. The burn occurred at 1000. How much lactated Ringer's is due in the first 8 hours, and by when?
- %TBSA: front of trunk 18% + right arm 9% = 27%.
- 24-hour total: 4 mL × 80 kg × 27 = 8,640 mL.
- First half (4,320 mL) over the first 8 hours from the time of the burn — by 1800 — about 540 mL/h.
- The remaining 4,320 mL runs over the next 16 hours (about 270 mL/h). Adjust to keep urine output about 0.5 mL/kg/h (40 mL/h for this client).
Answer. 4,320 mL by 1800 (8 hours after the burn, not after arrival).
Phases of burn care
Fluid and electrolyte problems change across the phases.
Nursing priorities
Burns affect nearly every system.
- Circumferential burns: check distal pulses, color, and sensation; tight eschar can cause compartment syndrome and may need escharotomy. Circumferential chest burns can restrict breathing.
- Electrical burns: skin wounds underestimate deep damage; place on a cardiac monitor and watch for dark urine (myoglobin) and kidney injury.
- Nutrition: very high calorie and protein needs; enteral feeding is often started early.
- GI: stress (Curling) ulcers — expect acid suppression.
- Contractures: the position of comfort is often the position of contracture; use splints, range of motion, and positioning in extension.
- First aid for minor burns: cool running water (not ice) for about 20 minutes; remove jewelry; cover with a clean dressing. Avoid cooling large burns long enough to cause hypothermia.
NGN-style case
Prioritizing the airway.
A client rescued from an enclosed house fire has burns on the face and arms, singed eyebrows, soot around the mouth, and a hoarse voice. SpO₂ reads 98%. The client is confused and has a headache. What are the priorities?
- Recognize cues: facial burns, soot, hoarseness → inhalation injury with airway swelling risk.
- Confusion and headache with a normal SpO₂ suggest carbon monoxide poisoning; pulse oximetry cannot distinguish carboxyhemoglobin.
- Give 100% oxygen by non-rebreather mask, prepare for early intubation, and obtain an ABG with carboxyhemoglobin.
- Then start fluid resuscitation with large-bore IV access and assess burn depth and size.
Answer. Airway and oxygenation first: 100% oxygen, prepare for early intubation, and check carboxyhemoglobin — do not trust the SpO₂.