Med-Surg · Integumentary
Burns & Pressure Injuries
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.
1. Overview and Pathophysiology
Burns destroy skin’s barrier, fluid regulation, and thermoregulation. Depth (superficial → full-thickness) and %TBSA drive fluid needs and outcomes. Early death risks: airway edema and shock; later: infection and hypermetabolism.
Pressure injuries result from prolonged pressure ± shear over bony prominences, causing ischemia. Staging uses definitions. Prevention is a nursing-sensitive quality outcome.
2. Causes and Risk Factors
- Burns: flame, scald, contact, chemical, electrical, radiation; inhalation injury with enclosed-space fires
- Pressure injuries: immobility, moisture, poor nutrition, perfusion deficits, devices (O₂ tubing, catheters), age, sensory loss
3. Signs and Symptoms
Burns: pain (partial-thickness very painful; full-thickness may be insensate), blisters, eschar, edema. Inhalation: singed nasal hairs, soot in sputum, hoarseness, stridor—airway emergency. Circumferential burns threaten distal perfusion / ventilation.
Pressure injuries: nonblanchable erythema (Stage 1) → open ulcer stages; undermining/tunneling; possible foul odor/drainage if infected. Dark skin tones: assess for color change, bogginess, temperature differences—not only “redness.”
4. Diagnostics and Labs
Lab reference ranges vary by laboratory. Always use your facility’s ranges.
| Test | Note | Nursing relevance |
|---|---|---|
| Carboxyhemoglobin | CO exposure | 100% O₂; pulse oximetry unreliable for CO |
| Hct, K⁺, Na⁺ | Early hemoconcentration / hyperkalemia | Fluid shifts |
| Albumin / prealbumin | Nutrition | Healing capacity |
| Wound cultures | When infection suspected | Avoid routine colonization swabs without indication |
| Braden / facility risk scale | ≤ 18 often = risk | Guides prevention bundle |
| TBSA charts (Rule of Nines / Lund-Browder) | Adults vs kids | Parkland calculations |
5. Priority Nursing Assessments
- Airway first with any burn/inhalation suspicion
- Breathing/circulation; remove smoldering clothing/jewelry; cool briefly per protocol (avoid ice/hypothermia)
- TBSA estimate; depth; circumferential checks; urine output
- Pain and anxiety
- Full skin survey for pressure risk; device-related pressure points
- Tetanus status; concomitant trauma
6. Priority Nursing Interventions
Burns:
- Airway/O₂; early intubation if airway edema likely
- Fluid resuscitation ( teaching formula: 4 mL × kg × %TBSA LR; half in first 8 hours from time of burn, rest over next 16)—follow burn-center protocol (formulas vary)
- Target UOP often ~0.5 mL/kg/hr (adults) or per burn team; electrical burns may need higher
- Pain control (IV opioids initially), infection control, temperature management, high-calorie/high-protein nutrition
- Escharotomy for compromised circulation/ventilation as performed by qualified providers
- Chemical: brush off powder, prolonged lavage per toxin guidelines; electrical: cardiac monitoring, hidden deep injury
Pressure injuries:
- Reposition at least q2h (individualize), offload heels, support surfaces, manage moisture, optimize nutrition/protein, never massage reddened bony prominences
- Stage accurately; photograph per policy; wound care orders (moist healing for many wounds)
7. Medications
| Class / examples | Role | Nursing considerations |
|---|---|---|
| IV opioids / multimodal analgesia | Burn pain | Procedural dosing before dressing changes |
| Topical antimicrobials (silver sulfadiazine, mafenide) | Burn wound | Sulfa allergy; mafenide can be painful / acid–base effects |
| Tetanus prophylaxis | Traumatic burns | Update if indicated |
| Antibiotics | Documented infection—not routine prophylaxis for all burns | Stewardship |
| Stress ulcer prophylaxis | Major burns | Per protocol |
| Vitamin C / zinc / protein supplements | Nutrition support | Dietitian-guided |
8. Patient Education
- Home burn first aid: cool water (not ice/butter), cover clean cloth, seek care for large/chemical/electrical/facial burns
- Scar/contracture PT and compression garment adherence
- Pressure injury: caregiver turning schedule, incontinence care, nutrition, report new skin changes early
- Sun protection on healed burns; itch management
9. Complications
- Airway obstruction, CO poisoning, cyanide (industrial fires)
- Burn shock, AKI, compartment syndrome, infection/sepsis
- Contractures, hypertrophic scars, PTSD
- Osteomyelitis under deep pressure injuries; fistula; sepsis
10. Memory Aids
- “Airway before ointment”
- “Parkland clock starts at burn time, not arrival”
- “Half in eight”
- “Don’t massage Stage 1 redness”
- “Stage 3 = fat; Stage 4 = bone/tendon/muscle”
11. NCLEX-Style Practice Questions
1. 70 kg client with 40% TBSA burns. Using Parkland (4 mL × kg × %TBSA), fluid volume in the first 8 hours?
A. 2,800 mL
B. 5,600 mL
C. 11,200 mL
D. 1,400 mL
Answer: B. Total 24-h volume = 4 × 70 × 40 = 11,200 mL; half (5,600 mL) in first 8 hours from injury time.
2. Which burn finding is the highest immediate priority?
A. Blistered forearm
B. Hoarseness with soot around the mouth after house fire
C. Pain score 6/10 on a superficial sunburn
D. Healed scar itching
Answer: B. Impending airway loss from inhalation injury.
3. Sacral wound with full-thickness skin loss and visible fat, no bone/tendon/muscle. Stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C. Fat visible without deeper structures = Stage 3.
4. Best prevention action for pressure injuries?
A. Massage reddened coccyx vigorously
B. Reposition frequently, offload heels, keep skin clean/dry, optimize nutrition
C. Keep HOB always at 90° with shear
D. Restrict protein
Answer: B. Evidence-based prevention bundle elements.
5. Why is urine output closely watched during burn resuscitation?
A. It measures pain
B. It is a practical marker of adequate end-organ perfusion during fluid replacement
C. It replaces the need for vital signs
D. It diagnoses CO poisoning
Answer: B. Titrate fluids to perfusion targets such as UOP per protocol.
References
American Burn Association. (n.d.). Burn center referral criteria and educational resources. https://ameriburn.org/
National Pressure Injury Advisory Panel. (n.d.). Pressure injury staging illustrations and definitions. https://npiap.com/
Agency for Healthcare Research and Quality. (n.d.). Pressure injury prevention. https://www.ahrq.gov/
MedlinePlus. (n.d.). Burns. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/burns.html
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page