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Clinical Nursing Skills

8.4 Burn Injuries and Management

Clinical Nursing Skills8.4 Burn Injuries and Management

Learning Objectives

By the end of this section, you will be able to:

  • Identify the different types of tools used for burn assessments
  • Describe the nurse’s role in burn injury management
  • Recognize complications that occur in different body systems because of burn injuries

Globally, more than 175,000 deaths related to burns occur annually (World Health Organization, 2018). The skin is the largest organ of the body. Burns on the skin can range from very small to covering large portions of the body. They can range from mild to life-threatening based on the cause, depth, and amount of surface tissue they cover. While they are wounds, they are frequently more complex than wounds we have discussed thus far. Furthermore, their impacts on the body are somewhat different based on the cause, requiring different types of assessment and management and creating different types of complications. Severe burns impact health, well-being, and mortality for up to ten years after the initial injury (Jeschke et al., 2020).

Burn Injury Assessment

Burn injury assessment is similar to assessment of other wounds. The burn itself must be examined to determine treatment and management. However, the type of burn must also be known. As with the cause of some types of wounds, such as diabetic foot ulcers, the cause of the burn is critical to ensuring appropriate treatments. Finally, burn assessment includes the percentage of the body surface that was burned. Clinicians use these three factors to develop management and treatment strategies for patients with burns: burn level or degree, cause, and amount of impacted body surface.

Cultural Context

Populations at Higher Risk

Due to differences in access to medical care and issues of healthcare equity, higher risk populations, such as immigrant populations, people with low incomes, or people who are marginalized or are experiencing homelessness, are more likely to experience burns and are less likely to have access to all the supportive care needed to return to their full health and baseline. Organizations such as the World Health Organization and the American Burn Association are actively engaged in decreasing the burden and risk of burn-related injuries for these populations, through lobbying for legislative changes (such as decreased flammability for children’s clothing) and engaging in grassroots fire-prevention campaigns (Jeschke et al., 2020).

Burn Levels

Burn levels are determined by the depth of related tissue damage. They are classified into one of three types based on how deeply the burn extends into the skin (Table 8.12 and Figure 8.14).

Burn Level Skin Involvement Signs Example Duration
Superficial (first-degree) burn Epidermis only Warm, red, painful, soft, blanches when pressed Sunburn Usually self-limiting and resolves in a few days
Partial-thickness (second-degree) burn Epidermis and into dermis Very painful, red, blistered, moist, blanches when pressed Burn from hot liquid or surfaces Requires treatment and healing of three to eight weeks
Full-thickness (third-degree) burn Epidermis, all of dermis, into subcutaneous fat or deeper structures Not painful, white, brown, or charred, firm and leathery texture, no blanching Flames, superheated gases Requires extensive treatment and healing of several months
Fourth-degree burn (described in some sources) Epidermis down into bone and muscle Blackened skin and tissues, life-threatening Burn from a building fire Frequently leads to amputation; very long recovery
Table 8.12 Burn Classification Levels (Source: Schaefer & Szymanski, 2023; Jeschke et al., 2020.)
Diagram showing the three degrees of burns.
Figure 8.14 Compare the differences between first-, second-, and third-degree burns. (credit: modification of “Burn Degree Diagram” by "Persian Poet Gal"/Wikimedia Commons, CC BY 3.0)

Types of Burns

The cause of burns greatly impacts their treatment. Burns can be caused by a variety of environmental exposures. Heat, chemicals, radiation, and electricity all cause burns. Any of them can be life-threatening if they are severe enough. It is critical for nurses to understand and recognize the various types of burns and the care required for each of them.

Thermal Burns

Burns related to temperature, known as thermal burns are arguably the most common type of burn for which patients seek treatment (Table 8.13). The severity of the injury depends on the degree of the exposure and the amount of time the skin was exposed (Figure 8.15) (Żwierełło et al., 2023).

Burn Type Description
Hot liquids
  • Also called scalding
  • Caused by exposure to hot liquids
  • Superficial to partial-thickness burns that heal
  • Most common burn in children
Dry heat
  • Usually caused by direct contact with flame or radiant heat source
  • Usually causes partial- to full-thickness burns that require surgery
  • Complicated by other injuries such smoke inhalation
Contact injury
  • Caused by touching a hot object
  • Often occurs when a person is unable to move away from a hot object (e.g., due to a seizure, mobility issues, or loss of consciousness)
  • Frequently causes full-thickness burns that require surgery
Extreme cold
  • Also called frostbite
  • Occurs when water in the tissue freezes
  • Causes deep-tissue injury and may lead to tissue death (necrosis)
Table 8.13 Different Types of Thermal Burns (Source: Żwierełło et al., 2023; Jeschke et al., 2020.)
An image showing third and fourth degree burns on a patient.
Figure 8.15 Note the severity of the third- and fourth-degree burns that covers this patient’s entire torso. (credit: “A full-thickness 3rd degree thermal burn” by Żwierełło et al., CC BY 4.0)

Real RN Stories

Burned Patient

Nurse: Beth, BSN
Clinical setting: Step-down unit
Years in practice: 25
Facility location: Suburb in Georgia

Our hospital is part of a hospital group here in Georgia. We all use the same policies and procedures and generally follow the same rules. One day, engineering came in to reset all of our blanket heaters five degrees lower than we kept them, and locked them at that temperature. Several of us were frustrated because we felt like the temperature was set too low to really help patients when they were cold, and we knew that we would have to change out their blankets more frequently. Then we received an email from the patient safety office that we were not allowed to use the microwave to heat towels or blankets for patients. Then, a new policy came out about various heat sources and patients, which we all had to read and sign.

At the next staff meeting, we asked our nurse manager if we could get the temperature turned back up on the blanket heater. Our manager told us that there had been an incident in the ICU of one of our company’s other hospitals. A nurse had microwaved a towel to warm it up and left it in a wrapped/rolled up position. Then she placed it on a patient’s chest without unwrapping. The towel continued to increase in heat since it was not exposed to environmental temperatures and burst into flames, burning the patient. Once we got over being horrified about that thought, our manager explained further.

After the incident, the safety department looked at all of the ways that we provide heat for patients and compared them with national guidelines. To prevent any future events, they had developed a new policy about heat sources and also determined to set all blanket warmers across the entire agency at the same temperature, with no exceptions or alterations. I cannot say that I blame them, but what a horrible way to realize there is a potential problem.

Chemical Burns

Accidental burns caused by exposure to various chemicals are known as chemical burns. Most occur at home or in various industries; however, chemicals have been used intentionally in targeted attacks against individuals or groups, and in warfare. The severity of chemical burns depends on the type of chemical, its concentration, the body surface exposed, the amount of exposure time, and the action of the specific chemical (Table 8.14) (Żwierełło et al., 2023). When a patient has been exposed to a chemical, always research the effects of that chemical. Some readily absorb and continue to impact the skin and underlying structures well after the chemical itself has been washed off.

Chemical Class Examples Burn Characteristics
Acid Hydrofluoric, acetic, formic, sulphuric, nitric, hydrofluoric
  • Localized and temporary
  • Destroys proteins in skin and causes localized necrosis
Alkali Sodium hydroxide, potassium hydroxide, calcium hydroxide, ammonia
  • Causes progressive liquefaction necrosis (liquefaction and death of body tissues)
  • Penetrates deeply
  • Continues to impact tissues after being removed
Oxidizers Bleaches, peroxides, chromates
  • Pain, redness, localized swelling, and blistering
Miscellaneous Hair dye, mustard gas, white phosphorus
  • Varies by type; may include respiratory distress and blistering
Table 8.14 Chemical Classes and Burn Characteristics (Source: Żwierełło et al., 2023; Jeschke et al., 2020.)

Cultural Context

Risk of Chemical Burns for Farmers

Farmers are at high risk for chemical burns from the chemicals they use on their fields, particularly nitrogen fertilizers such as anhydrous ammonia. Anhydrous ammonia is a desiccant—it pulls out all moisture from any surface it touches, including the skin—and causes caustic burns and then freezing due to the rapid loss of body heat. When providing care for patients who are farmers, provide safety information to prevent chemical burns. Encourage them to use appropriate personal protective equipment whenever dealing with fertilizers. If exposed, they should immediately flush the skin with gallons of water and seek medical treatment (Minnesota Department of Agriculture, n.d.; Doss, n.d.).

Radiation Burns

Radiation burns are caused primarily by three different types of rays; alpha, beta, or gamma (Żwierełło et al., 2023). Exposure may occur during cancer treatment. Alpha rays cannot penetrate the skin but cause extensive internal burns if inhaled or ingested. Beta rays only penetrate a short distance into the skin and cause superficial burns. Gamma rays penetrate deeply into the tissues, causing full-thickness burns, and also impact internal organs such as the lungs. Patients exposed to gamma radiation are also at risk of acute radiation syndrome (ARS). ARS is an acute illness related to full-body exposure to high levels of radiation (Centers for Disease Control and Prevention, 2018). It may impact the cardiovascular system, gastrointestinal tract, and/or bone marrow and is frequently fatal.

Electrical Burns

Skin is not a good conductor of energy. When an electrical source meets skin and generates heat, damaging local tissue and causing an electrical burn. Severity of electrical burns is determined by several factors: the amount of electricity (voltage), the type of current (AC or DC), how long the contact was made, and how the electricity travels through the body (Żwierełło et al., 2023). Electricity will find a way to move through the human body, and with severe electrical burns there will be visible burns at both the entry and exit points(Figure 8.16). Approximately 5 percent of all burns are electrical burns (Żwierełło et al., 2023). Nursing considerations for patients with electrical burns include the following:

  • Always check for entrance and exit points with electrical burns.
  • If there are entrance and exit points, all the tissue between the two points is also burned and impacted by the movement of the electricity through the body.
  • Internal electrical burns can cause cardiac arrhythmias, muscle breakdown, renal failure, and other difficulties.
  • Always examine patients with electrical burns for injuries related to falls as they frequently fall after the electrical shock (Żwierełło et al., 2023).
Images showing various electrical burns: (a) electrical burn entry wound; (b) electrical burn exit wound; (c) electrical burn on the hand.
Figure 8.16 These images show various electrical burns: (a) electrical burn entry wound; (b) electrical burn exit wound; (c) electrical burn on the hand. (credit: (a) modification of “Electrical burn entrance wound” by OSHA/Wikimedia Commons, Public Domain; (b) modification of “Electrical burn exit wound” by OSHA/Wikimedia Commons, Public Domain; (c) modification of “Electrical burn on hand” by NIHOSH/Wikimedia Commons, Public Domain)

Percentage of Body Surface

The percentage of the body’s surface that is burned is the third important issue to assess. The greater the total body surface area (TBSA) of a burn, the higher the likelihood of serious complications and death (Żwierełło et al., 2023). For example, if more than 30 percent of the TBSA is burned, hypovolemia is likely as the body loses blood, plasma, and fluid through the exposed tissues and the inflammatory system goes into overdrive. This can lead to burn shock in which the circulatory system becomes dysfunctional and unable to compensate for the loss of blood, plasma, and fluid, even with aggressive fluid replacement (Jeschke et al., 2020). This in turn may lead to cardiac dysfunction, inadequate tissue perfusion, and potential organ failure (Żwierełło et al., 2023). TBSA covered in a burn can be determined by two strategies: Rule of Nines and the palmar method.

Clinical Judgment Measurement Model

Recognize Cues: Determining TBSA of a Patient’s Burn

For most patients, determining the percentage of their body surface covered in a burn will be determined by using one of two strategies.

  • Rule of Nines is common for burns over large surface areas (Figure 8.17). The head and each arm represent 9 percent each of TBSA. The chest and abdomen, entire back, and each leg are 18 percent each. The perineal area is 1 percent. Thus, a patient whose entire right arm and back were burned would have a TBSA of 27 percent.
    Image showing how to easily calculate the burn percentage for a patient.
    Figure 8.17 Using this image, it is easy to calculate the burn percentage for a patient. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
  • The palmar method is used for smaller burns. With this method, look at the patient’s palm, not including their fingers. A burn the size of their palm will be an estimated 0.5 percent of their TBSA. A burn the size of their palm including their fingers will be an estimated 1 percent of their TBSA.

Remember, only partial- and full-thickness areas of burning are considered when determining TBSA for medical treatment (Schaefer & Szymanski, 2023).

Burn Injury Management

The goals of burn care are simple: “no death, no scar, no pain” (Jeschke et al., 2020). When a patient comes into the emergency department, urgent care center, or provider’s office with a burn, the assessment of burn type, cause, and affected TBSA will dictate the initial burn management. Most minor burns can be treated in any healthcare area. These should be treated with a Four Cs approach:

  • Cool the burn with tap water or saline.
  • Clean the area with mild soap and water, leaving smaller blisters intact.
  • Cover the burn with topical antibacterial ointments and dressings.
  • Provide comfort via pain medications (prescription or over the counter) and/or splints for support

More severe burns require different levels of burn management. In the United States, most patients with burns greater than 10 percent of their TBSA, burns that are full-thickness, burns to sensitive areas (face, hands, feet, genitalia, joints), chemical or electrical burns, and/or associated traumatic injuries are transferred to burn centers for treatment (Schaefer, 2023).

The immediate steps after a burn involve removing the cause of the burn (Żwierełło et al., 2023). For thermal and electrical burns, the cause will be removed prior to the patient arriving in the healthcare location. For chemical and radiation burns, this is frequently not the case, and these patients must undergo decontamination (removal of residual chemical or radiological particles) prior to receiving full assessment and treatment (Figure 8.18). Decontamination should be performed prior to transfer of a patient to a burn center.

Graphic showing the importance of decontamination for patients exposed to chemicals and radiation.
Figure 8.18 Decontamination is a critical first step for patients exposed to chemicals and radiation (Chilcott, 2019; Occupational Safety and Health Administration , n.d.; Collins et al., 2020; Wiesner et al., 2019; Centers for Disease Control and Prevention, 2018). (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Resuscitation for Burn Injury

Once any needed decontamination is completed, perhaps the most important component to managing patients who have been burned is fluid resuscitation, which is the administration of IV fluids to ensure adequate intravascular fluid. With burns, the body quickly sends fluids into the damaged tissues as part of the body’s attempts to return to homeostasis (system stability or equilibrium) (Żwierełło et al., 2023). A type of shock due to decreased fluid volume in blood vessels that impacts the blood flow and transport of oxygen to organs and tissues known as hypovolemic shock is a real risk for patients with burns that cover more than 10 percent of TBSA (Carter, 2022). Hypovolemic shock occurs because vasodilation and capillary permeability, due to the immune and inflammation process happening on a systemic level, allow fluids to shift in the vasculature into tissue spaces.

Parkland Burn Formula

The Parkland burn formula is a commonly used formula for determining the amount of fluid resuscitation is needed for patients who have been burned (Figure 8.19). The goal of fluid resuscitation is maintaining a urine output greater than 0.5 mL/kg/hr. It should begin as soon as possible for patients with burns covering 20 percent or more TBSA, even before patients are transferred from their initial triage location.

An illustration demonstrating the Parkland burn formula.
Figure 8.19 The appropriate lactated Ringer’s (LR) fluid replacement amount is calculated using the Parkland burn formula, using patient weight and TBSA burn percentage (Adapted from Schaefer & Szymanski, 2023). (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Improving Care Coordination

Second- and third-degree burns typically require lengthy hospital admissions and complex treatment regimens. As previously mentioned, patients with severe burns should be transferred to designated burn centers that have large interdisciplinary teams dedicated to meeting the complicated needs of patients who have been burned. However, up to 20 percent of the U.S. population does not reside near a burn center, a situation that is much more severe in other countries (Jeschke et al., 2020). No matter where care is provided, patients who have been burned require a well-coordinated and large interdisciplinary team (Table 8.15) (Johns Hopkins Medicine, n.d.).

Multidisciplinary Team Burn Program Services
  • Providers, including plastic and orthopedic surgeons, infectious disease providers, and hospitalists
  • Nurses specializing in burn care
  • Psychologists/psychiatrists
  • Physical, occupational, respiratory, and recreational therapists
  • Dieticians
  • Social workers, case managers, and vocational counselors
  • Wound care and pain management
  • Physical therapy and occupational therapy to prevent contractures and manage activities of daily living
  • Surgical procedures including cosmetic reconstruction and skin grafting
  • Psychological counseling for patient and family and medications as needed to manage depression, grief, fear, and anxiety
  • Nutritional counseling
  • Job counseling and retraining
Table 8.15 Care Coordination in Patients Who Have Been Burned

Complications of Burn Injury

In addition to suffering the acute effects of burns, patients are also at risk for complications and associated injuries. Patients who have been burned may also have inhalation injuries, fluid imbalances, body temperature abnormalities, and other physical injuries. They are also at risk for infection and limited mobility, depending on the nature and extent of their injuries. All patients are also at risk for psychological trauma from both the experience of being severely injured and the process of healing and adapting to any permanent changes the injuries may have caused. It’s important for the nurse to be aware of the potential long-term consequences of burn injuries so they can assess and monitor patients for progress and signs of complications.

Respiratory Complications

Respiratory complications are also common with burns, particularly in patients who also experienced inhalation injuries caused by breathing in particulates such as smoke, exposure to extreme temperatures such as heat from fires, or chemical burning of upper airways (Żwierełło et al., 2023; Jeschke et al., 2020). Inhalation injuries related to burns fall into three categories: system toxicity related to chemicals such as carbon monoxide and cyanide, thermal injuries to upper airway, and chemical injuries to entire airway (upper and lower) (Jeschke et al., 2020). It is important for the nurse to take note that burns on the head, neck, and chest can be correlated to inhalation injuries, and to aggressively protect a patient’s airway by anticipating intubation and mechanical ventilation.

Low Blood Volume

Hypovolemia can lead to burn shock. When a burn occurs, particularly a second-degree or greater burn over more than 10 percent of the TBSA, the body loses intravascular and interstitial fluid as the natural immune response rushes to manage the wound (Jeschke et al., 2020). However, with burns, the human immune response tends to overcompensate at the wound site, which can negatively impact blood volume to the rest of the body, including the heart. As a result, even with aggressive fluid resuscitation, cardiac function can become impaired, decreasing oxygenation to tissues. The combination of low blood volume in the vascular system with cardiac dysfunction can affect other internal organs as well.


For patients with burns covering more than 40 percent TBSA, particularly those with thermal burns, loss of thermoregulation (the body’s ability to regulate its own temperature) is a potential complication (Żwierełło et al., 2023). When thermoregulation is disrupted for patients who have been burned, they become prone to hypothermia (an abnormally low body temperature).


Infections, particularly sepsis (multiorgan, systemic infection), are common among patients with burns due to large areas of exposed tissue and the dysregulation of the immune system as discussed previously (Jeschke et al., 2020). Patents with burns are particularly susceptible to bacterial infections, but also fungal, yeast, and even viral infections. Nurses have a responsibility in preventing infection. Examples include strict hand hygiene, contact precautions, wearing a mask, inherent and gloves, essentially placing a patient in a more protective isolation because they won’t be able to fight off an infection, like a healthy individual so they need to be protected from the outside world. Prevention and early identification of infection are critical components of burn management. Nurses should expect to use strategies, such as using topical antibiotic ointments and culturing wound sites when infection concerns arise (Żwierełło et al., 2023).

Scarring, Contractures, and Mobility

Burns scars can be physically traumatic for people who have been burned and can have profound and permanent impacts on mobility. Because scar tissue is not elastic, it causes skin mobility to become restricted, which can also affect joint mobility (Figure 8.20).

Figure 8.20 Scar tissue can have permanent impacts on mobility (Żwierełło et al., 2023). (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Prevention may include physical therapy, splinting (holding a body part in a desired position with medical aids), and reconstructive surgery, such as skin grafting (a piece of healthy skin is transplanted from one area of the body to another). Skin grafting is often used to decrease the impacts of scarring and improve both appearance and the use of affected areas (Żwierełło et al., 2023).

Psychological Trauma

Severe burns and trauma can lead to profound psychological trauma. Patients with minor burns experience more depression and anxiety than the general population (Jeschke et al., 2020). Many studies have shown that patients who have suffered severe burns report lower quality of life and increased anxiety, pain, and depression even after their physical wound has healed (Jeschke et al., 2020). Furthermore, there is strong evidence that patients who experience severe burns, depression, and post-traumatic stress experience difficulties returning to their normal lives (Jeschke et al., 2020). Thus, early and regular mental health assistance and services are an important component of interdisciplinary teams, to assist with psychological trauma related to the burn and encourage healthy recovery.


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