Burns Nursing Care for the NCLEX: Assessment and Management

Burn Classification

• Superficial (1st degree): Epidermis only. Red, painful, no blisters. Example: sunburn
• Partial thickness (2nd degree): Epidermis + dermis. Blisters, very painful, moist
• Full thickness (3rd degree): All skin layers. Dry, leathery, painless (nerve destruction), white/brown/black
• 4th degree: Extends into muscle, bone, tendon

Rule of Nines (Adult)

• Head: 9%, each arm: 9%, each leg: 18%, anterior trunk: 18%, posterior trunk: 18%, perineum: 1%

Fluid Resuscitation (Parkland Formula)

4 mL × body weight (kg) × %TBSA burned

Half in first 8 hours (from time of burn), remaining half over next 16 hours. Use lactated Ringer's.

Nursing Priorities

1. Airway (especially with facial burns, singed nasal hairs)
2. Fluid resuscitation and monitoring I&O
3. Pain management
4. Wound care and infection prevention
5. Monitor for compartment syndrome in circumferential burns

Review our Physiological study guide and Physiological flashcards.