• Black, peeling skin and blisters: mixed deep partial-thickness and full-thickness burns. Black, leathery skin can be eschar, which may need urgent surgical assessment.
• Hypothermia: loss of normal skin temperature control. It worsens shock and clotting problems.
• Dehydration, edema, and hyponatremia: major fluid and electrolyte shifts after burns. The patient can be intravascularly dehydrated even while tissues are swollen.
• Dyspnea (if “disappenea” means difficulty breathing): possible airway/inhalation injury, pulmonary edema, carbon monoxide exposure, or shock. This is immediately life-threatening.

Immediate priorities: ABCDE

1. Airway: Look for facial burns, soot in mouth/nose, hoarse voice, singed nasal hairs, stridor, or worsening swelling. Call anesthesia/burn team early because airway swelling can progress rapidly.
2. Breathing: Give high-flow oxygen, monitor SpO₂, respiratory rate, chest movement, and obtain ABG/co-oximetry if smoke exposure is possible. A normal pulse oximeter reading does not rule out carbon monoxide poisoning.
3. Circulation: Two large-bore IV lines through unburned skin if possible; assess BP, pulse, mental status, capillary refill, urine output, and calculate % total body surface area burned. Major burns need protocol-based IV fluid resuscitation with frequent reassessment, not unmonitored large-volume fluid administration.
4. Disability: Assess consciousness, pain, glucose, and temperature.
5. Exposure/environment: Remove hot or contaminated clothing and jewelry, cover burns with clean dry sheets or dressings, and actively warm the patient and fluids. Do not use ice directly on burns.

Urgent investigations and monitoring

• Continuous ECG, pulse oximetry, frequent vital signs, core temperature
• CBC, electrolytes including serial sodium, renal function, glucose, ABG/VBG, lactate, and carboxyhemoglobin when smoke inhalation is suspected
• Strict hourly urine output using a urinary catheter in major burns
• Burn size and depth charting, photographs if permitted
• Tetanus status and analgesia assessment

Important safety points

• Do not give prophylactic systemic antibiotics routinely unless infection or another indication is present.
• Do not rapidly correct hyponatremia without identifying its severity, duration, symptoms, fluid status, and cause. It requires serial monitoring and clinician-directed correction.
• Circumferential chest burns with worsening breathing, or circumferential limb burns with reduced pulses, increasing pain, numbness, or cool extremities may require urgent escharotomy assessment.
• This patient needs urgent burn-center/surgical referral, particularly because of suspected deep burns, hypothermia, electrolyte disturbance, edema, and respiratory symptoms.

• Inhalation injury or airway burns
• Smoke inhalation with carbon monoxide poisoning
• Acute respiratory compromise from chest burns, lung injury, or fluid overload

How the burns may be classified

• Black, dry, leathery/charred skin suggests a full-thickness burn.
• Blisters and peeling skin suggest a partial-thickness burn.
• Both may coexist, so the formal description is often:
  “Mixed partial- and full-thickness thermal burns involving ___% TBSA, with burn shock.”

Diagnoses/complications to document

1. Major burn injury, with site, cause, depth, and % total body surface area (TBSA).
2. Full-thickness burn/eschar where black leathery skin is present.
3. Partial-thickness burn where blisters are present.
4. Burn shock or acute hypovolemia due to fluid loss and capillary leak.
5. Hypothermia.
6. Hyponatremia.
7. Suspected inhalation injury/acute respiratory distress until excluded.
8. Possible circumferential-burn complications if a limb or chest is encircled by tight burned skin.

1. Burn assessment

• Estimate burn size: % total body surface area (%TBSA), using the Rule of Nines or Lund-Browder chart.
• Assess burn depth: superficial, partial-thickness, deep partial-thickness, or full-thickness.
• Document location, circumferential burns, pulses, sensation, and photographs if local policy permits.
• Assess for compartment syndrome/eschar constriction if limb swelling, reduced pulses, numbness, or severe pain occurs. Compartment pressure measurement may be needed.

2. Immediate monitoring

• Continuous vital signs: temperature, heart rate, blood pressure, respiratory rate, oxygen saturation.
• Continuous ECG monitoring.
• Strict input-output charting and hourly urine output through a urinary catheter in a major burn.
• Serial neurologic assessment, capillary refill, and peripheral pulses.

3. Blood tests

• CBC: hemoglobin/hematocrit, white blood cell count, platelets.
• Serum electrolytes: especially sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate.
• Renal function: urea/BUN, creatinine.
• Blood glucose.
• ABG or VBG with lactate: assesses oxygenation, carbon dioxide, acidosis, and severity of shock.
• Coagulation profile: PT/INR, aPTT, fibrinogen, especially in extensive burns or suspected coagulopathy.
• Blood group, cross-match, and screen if significant burns or surgery is likely.
• Serial sodium measurements to monitor and safely manage hyponatremia.

4. Tests for dyspnea or smoke inhalation

• Co-oximetry with carboxyhemoglobin level to detect carbon monoxide poisoning.
• Methemoglobin level if chemical exposure or smoke inhalation is suspected.
• Chest X-ray: baseline assessment and to identify trauma, edema, aspiration, or other lung pathology.
• ECG and cardiac enzymes if there was electrical injury, severe hypoxia, chest symptoms, or carbon monoxide exposure.
• Fiber-optic bronchoscopy if inhalation injury is suspected. It directly assesses airway soot, inflammation, ulceration, and obstruction, and is considered the definitive diagnostic test for inhalation injury.
• CT chest is not routinely first-line, but may be used if there is trauma or uncertainty after initial evaluation.

5. Urine tests

• Urinalysis for blood and myoglobin.
• Urine myoglobin and serum creatine kinase (CK) if electrical burn, crush injury, or dark urine is present, to detect rhabdomyolysis and kidney-injury risk.

6. Other tests when indicated

• Wound swab/culture and blood cultures only if infection or sepsis is clinically suspected. They are not routine tests immediately after a fresh burn.
• Pregnancy test for patients of child-bearing potential before imaging or certain treatments.
• Tetanus immunization history must be checked, though this is not a diagnostic test.

“Mixed partial- and full-thickness burns, %TBSA to be calculated; complicated by hypothermia, hypovolemia/burn shock, hyponatremia, and dyspnea. Evaluate urgently for inhalation injury and carbon monoxide poisoning with ABG/co-oximetry, carboxyhemoglobin, CXR, ECG, and bronchoscopy if indicated.”

Priority tests for this case

1. CBC
2. Serum electrolytes, including repeat serum sodium
3. Urea/BUN, creatinine, glucose
4. ABG with lactate
5. Carboxyhemoglobin by co-oximetry
6. Calcium, magnesium, phosphate
7. Coagulation profile
8. CK, urinalysis, and urine myoglobin if electrical injury/crush injury or dark urine
9. Group and crossmatch

Priority abnormal findings to write in the care plan

• Hyponatremia: Na⁺ 128 mmol/L
• Dehydration / reduced renal perfusion: raised BUN and creatinine, concentrated urine
• Possible burn shock / tissue hypoperfusion: raised lactate with metabolic acidosis
• Respiratory compromise: low PaO₂ and dyspnea
• Possible smoke inhalation/carbon monoxide exposure: raised carboxyhemoglobin, if relevant to the history
• Risk of rhabdomyolysis and acute kidney injury: raised CK, particularly with electrical burns

Main Laboratory Investigations for Burn Care Plan

Sample Medication Chart for Major Burn Patient

Important note for this patient

• Do not list 3% hypertonic saline routinely for hyponatremia. It is reserved for selected severe symptomatic cases and requires close medical supervision with serial sodium measurements.
• Because the patient has dyspnea, oxygen therapy and airway management may be urgently required, but oxygen is usually written separately under treatment orders rather than in a medication chart.
• Topical antimicrobial therapy is commonly used for deep burns, while routine systemic prophylactic antibiotics should be avoided in acute burns without infection, as summarized in this burn-management review.

Medication Chart for a Major Burn Patient

Important care-plan notes

• Hyponatremia should be managed with prescribed fluids and serial sodium monitoring. Do not independently list hypertonic saline unless the clinician has ordered it for severe symptomatic hyponatremia.
• If the patient has dyspnea or suspected smoke inhalation, high-flow oxygen and possible airway intervention are urgent treatment orders, although oxygen is usually recorded under respiratory therapy rather than the medication chart.
• Opioids are commonly needed for severe burn pain, especially during dressing changes. Topical antimicrobial choice should follow the burn unit’s wound-care protocol. The WHO burn-management guidance includes tetanus prophylaxis and topical wound treatment as part of burn care.

Physical Examination of a Burn Patient

1. General appearance

• Patient may appear distressed, anxious, restless, or in severe pain.
• Assess level of consciousness: alert, drowsy, confused, or unconscious.
• Observe for signs of dehydration: dry mouth, thirst, poor skin turgor, reduced urine output.
• Check for hypothermia: cold extremities, shivering, low body temperature.

2. Vital signs

3. Airway examination

• Facial burns, burnt eyebrows, or singed nasal hairs
• Soot around the mouth or inside nose/oral cavity
• Hoarse voice, cough, carbonaceous sputum
• Swelling, redness, blistering, or burns inside the mouth
• Stridor, wheeze, difficulty speaking, or increasing dyspnea

4. Respiratory system

• Inspect chest movement and work of breathing.
• Note respiratory rate, use of accessory muscles, cyanosis, cough, and sputum.
• Auscultate for wheeze, crackles, reduced air entry, or stridor.
• Look for circumferential chest burns that may restrict chest expansion.

5. Cardiovascular system

• Check pulse rate, rhythm, strength, and peripheral perfusion.
• Assess capillary refill, skin color, temperature, and peripheral pulses.
• Look for signs of burn shock: tachycardia, weak pulse, hypotension, delayed capillary refill, cold clammy extremities, and reduced urine output.
• Examine for edema, especially around burned limbs.

6. Neurological examination

• Assess Glasgow Coma Scale or level of consciousness.
• Check orientation to time, place, and person.
• Observe for restlessness, agitation, confusion, or reduced responsiveness, which may indicate hypoxia, carbon monoxide poisoning, shock, or severe hyponatremia.
• Assess motor and sensory function distal to circumferential burns.

7. Local burn-wound examination

• Partial-thickness burn: red or pink, moist, blistered, painful, blanches with pressure.
• Full-thickness burn: white, brown, or black; dry, leathery, non-blanching; may be painless because nerve endings are damaged.

8. Peripheral vascular assessment

• Check distal pulse, capillary refill, color, temperature, sensation, movement, and pain.
• Compare both sides.
• Report absent/weak pulse, increasing swelling, numbness, cold distal extremity, severe pain, or reduced movement urgently.
• These may indicate vascular compromise from tight eschar or compartment syndrome.

9. Abdominal, renal, and fluid-status examination

• Inspect for abdominal burns, distension, and tenderness.
• Assess hydration: dry mucosa, thirst, reduced skin turgor, and delayed capillary refill.
• Measure intake and output.
• Note urine color and amount. Dark or scanty urine may suggest dehydration, shock, or myoglobinuria.

Example physical-examination findings for this care plan

Patient is conscious but anxious and appears ill. Temperature is low, with dry mucous membranes and clinical signs of dehydration. Tachycardia, tachypnea, and possible hypotension may be present. Dyspnea is noted; examine for facial burns, soot around mouth/nose, singed nasal hairs, hoarseness, wheeze, stridor, and reduced air entry. Mixed partial- and full-thickness burns are present, with blisters, peeling skin, and black dry/leathery areas. Local edema is present. Assess and document %TBSA, burn depth, wound location, pain, sensation, peripheral pulses, capillary refill, and limb movement. Hyponatremia and signs of burn shock require close monitoring.