NLE Integumentary & Skin Integrity — Burns and Dermatologic DisordersRevision Notes

Exam Tips

• NLE frequently asks: 'Which burn is the MOST painful?' Answer: Superficial partial-thickness (2nd degree) — intact pain receptors with maximal stimulation.
• When a question describes a 'dry, leathery, white wound that does not blanch and is painless' — the answer is always full-thickness (3rd degree).
• Blisters = partial-thickness. No blisters + painless + leathery = full-thickness. No blisters + painful + blanches = superficial (1st degree).
• Remember: 4th degree is the most severe — charred appearance extending to muscle and bone.

Key Points

• Burns are classified by how many layers of skin are destroyed — depth determines pain, healing time, and need for grafting.
• Superficial (1st degree): Epidermis only. Red, dry, painful, blanches with pressure, NO blisters. Example: mild sunburn. Heals in 3–6 days, no scarring. NOT counted in TBSA.
• Superficial partial-thickness (2nd degree): Epidermis + upper dermis. BLISTERS present, moist red surface, MOST PAINFUL, blanches. Heals in 2–3 weeks, usually no graft needed.
• Deep partial-thickness (2nd degree): Extends into deeper dermis. Red to waxy white, DRIER, LESS PAINFUL (some nerve damage), slow capillary refill. May need grafting; can scar.
• Full-thickness (3rd degree): Entire epidermis and dermis destroyed. Dry, leathery, inelastic ESCHAR. White, waxy, tan, brown, or charred. PAINLESS (nerves destroyed). Does NOT blanch. REQUIRES SKIN GRAFTING.
• Fourth degree: Into muscle, fascia, bone. Charred. May need amputation.
• Key memory rule: More depth = less pain (nerve destruction). Full-thickness burns are PAINLESS at the center but the surrounding partial-thickness areas are very painful.
• Only partial-thickness and full-thickness burns are counted in TBSA estimation — NOT superficial (1st degree).

Definitions

Section Title

1. Burn Classification by Depth

Common Mistakes

• Confusing superficial partial-thickness (blistered, most painful) with full-thickness (dry, painless, leathery) — these are OPPOSITES in pain and moisture presentation.
• Including superficial (1st-degree) burns in TBSA calculation — these are EXCLUDED from the Parkland formula.
• Thinking full-thickness = most painful. In fact, full-thickness burns are PAINLESS at the center because nerve endings are destroyed.
• Forgetting that deep partial-thickness burns can be LESS painful than superficial partial-thickness burns, which often tricks students.

Formulas

Exam Tips

• Memorize: 'Head-Arm-Arm = 9+9+9 = 27%; Front torso = 18%; Back torso = 18%; Leg-Leg = 18+18 = 36%; Perineum = 1%'
• NLE calculation questions will describe which body parts are burned — add up the corresponding percentages, then apply Parkland.
• If a question mentions a child, the Rule of Nines does NOT apply accurately — Lund-Browder is more appropriate.
• For small isolated burns, recall that the patient's palm = ~1% TBSA.

Key Points

• The Rule of Nines is used for ADULTS to quickly estimate Total Body Surface Area (TBSA) burned.
• Head and neck = 9% (4.5% anterior + 4.5% posterior)
• Each upper extremity (arm) = 9% (4.5% anterior + 4.5% posterior)
• Anterior trunk (chest + abdomen) = 18%
• Posterior trunk (back) = 18%
• Each lower extremity (leg) = 18% (9% anterior + 9% posterior)
• Perineum/genitalia = 1%
• Total = 100%
• For CHILDREN: Use the Lund-Browder chart because children's heads are proportionally larger (head = up to 19% in infants) and legs are smaller.
• Palmar method: The patient's palm + fingers = approximately 1% TBSA. Useful for small, scattered, or irregular burns.
• ONLY partial-thickness and full-thickness burns are counted. Superficial (1st-degree) burns are EXCLUDED.

Definitions

Section Title

2. Estimating Burn Extent: Rule of Nines and Palmar Method

Common Mistakes

• Including superficial (1st-degree) burns in the TBSA count — NEVER include 1st-degree burns in Parkland formula calculations.
• Using Rule of Nines for children without adjustment — use Lund-Browder for children because head and legs have different proportions.
• Miscalculating: assigning 9% to a WHOLE leg instead of recognizing each leg = 18% (9% anterior + 9% posterior).
• Forgetting that each ARM = 9% (not 18%). Legs are 18% each, arms are 9% each — a common confusion in calculations.

Formulas

Exam Tips

• NLE LOVES the Parkland formula. Practice the full calculation: multiply 4 × kg × %TBSA, divide by 2, then divide by 8 to get the first-half infusion rate.
• Always re-check: 'Is the time from injury or from hospital arrival?' NLE answer choices will reflect this distinction.
• Urine output is the PRIMARY indicator of resuscitation adequacy — memorize adult target: 0.5 mL/kg/hr (~30–50 mL/hr); pediatric: 1 mL/kg/hr.
• Fluid choice = Lactated Ringer's. If a question offers 'Normal Saline' as an option for Parkland, it is WRONG.

Key Points

• The Parkland (Baxter) formula is the standard for calculating IV fluid resuscitation in major burn patients.
• Formula: 4 mL × body weight (kg) × %TBSA burned = Total fluid for first 24 hours.
• Fluid of choice: LACTATED RINGER'S SOLUTION (isotonic, most physiologic).
• Timing rule: Give 50% (half) of the total in the FIRST 8 hours FROM THE TIME OF INJURY (not from IV insertion or hospital arrival). Give remaining 50% over the NEXT 16 hours.
• CRITICAL: Time is calculated from the time of the burn injury, not from hospital arrival.
• If the patient arrives 2 hours post-injury, the first half must still be delivered by 8 hours post-injury — so it is infused over only 6 hours (not 8).
• Monitor adequacy of resuscitation primarily by URINE OUTPUT: Adults = 0.5 mL/kg/hr (~30–50 mL/hr); Children = 1 mL/kg/hr.
• Urine output is the BEST indicator of adequate fluid resuscitation — not the formula number itself.
• Other monitoring: Mean arterial pressure (MAP), mental status (sensorium), skin perfusion.

Definitions

Section Title

3. Fluid Resuscitation: The Parkland Formula

Common Mistakes

• Calculating the 8-hour deadline from time of hospital arrival instead of from TIME OF INJURY — this is the most common Parkland formula error in NLE.
• Using Normal Saline (NSS) instead of Lactated Ringer's for burn resuscitation — LR is always correct.
• Forgetting to adjust the infusion rate when a patient arrives late (hours post-injury) — the remaining first-half volume must be compressed into fewer hours.
• Using urine output of 30 mL/hr as a flat number without considering weight — in heavy patients, 30 mL/hr may be insufficient; use 0.5 mL/kg/hr.
• Including first-degree burn area in TBSA before applying the formula.

Exam Tips

• Memorize the electrolyte pattern: Emergent = HYPERkalemia + HYPOnatremia (fluid leaves vessels); Acute = HYPOkalemia + diuresis (fluid returns).
• Airway first, always. NLE questions on burn priority ALWAYS start with airway assessment — especially if inhalation injury is suggested.
• If a question asks about pain management route during emergent phase: IV is correct; IM/SC is wrong.
• Rehabilitation phase question: the major complication is CONTRACTURE. Prevent by: extension positioning + splinting + pressure garments + ROM exercise.
• 'What is the BEST indicator of adequate fluid resuscitation?' — Answer: URINE OUTPUT (30–50 mL/hr in adults).

Key Points

• Burn injuries progress through three phases: Emergent (Resuscitative), Acute, and Rehabilitation — each with distinct pathophysiology, electrolyte changes, and nursing priorities.
• EMERGENT PHASE (0 to 24–48 hours): Fluid shifts OUT of vessels (third spacing) → hypovolemia, edema. Electrolytes: HYPERKALEMIA (cell damage releases K+), HYPONATREMIA (Na+ trapped in edema). Greatest threat: HYPOVOLEMIC (BURN) SHOCK.
• ACUTE PHASE (48–72 hours until wound closure): Capillaries heal, fluid shifts BACK into vessels (diuresis). Electrolytes: HYPOKALEMIA (K+ re-enters cells + urinary loss), risk of FLUID OVERLOAD. Greatest threat: INFECTION AND SEPSIS.
• REHABILITATION PHASE (wound closure onward): Focus on function restoration, scar management, and psychosocial support. Greatest threat: CONTRACTURES.
• AIRWAY is ALWAYS the first priority in burn management — assess for inhalation injury before anything else (ABCs).
• Signs of inhalation injury: facial burns, singed nasal hair, carbonaceous (sooty/black) sputum, hoarseness, stridor, history of enclosed-space fire.
• For suspected carbon monoxide (CO) poisoning: give 100% HUMIDIFIED OXYGEN immediately.
• Analgesia route: IV opioids ONLY during emergent phase — IM and SC routes are unreliable due to edema and poor tissue perfusion.
• Curling ulcer (stress gastric ulcer): a complication during the acute phase; prevent with proton pump inhibitors (PPIs) or H2 blockers.
• Nutrition in acute phase: HIGH-CALORIE, HIGH-PROTEIN diet due to hypermetabolic state; add Vitamin C, Vitamin A, and Zinc for wound healing; early enteral feeding preferred.
• Rehabilitation priorities: prevent contractures (position in EXTENSION, splint), apply pressure garments (worn ~23 hrs/day), ROM exercises, psychosocial support.

Definitions

Section Title

4. Phases of Burn Injury: Assessment and Nursing Management

Common Mistakes

• Confusing emergent-phase electrolyte changes (HYPERKALEMIA) with acute-phase changes (HYPOKALEMIA) — opposite directions.
• Forgetting that the emergent phase is characterized by HYPOVOLEMIA (fluid leaves vessels) despite the patient looking edematous — the edema is interstitial, not intravascular.
• Giving IM or SC opioids during the emergent phase — absorption is unreliable; always give IV.
• Neglecting airway as the first priority — starting IV fluids before checking for inhalation injury is incorrect prioritization.
• Positioning burn patients in FLEXION for comfort — this CAUSES contractures. Always position in EXTENSION.

Exam Tips

• For chemical burns, the sequence is: BRUSH dry chemicals first → FLUSH with copious water/saline. Do NOT neutralize.
• Electrical burns: think ECG monitoring + dark urine (myoglobinuria) + AKI risk.
• Inhalation injury questions: singed nasal hair + sooty sputum + hoarseness = immediate 100% humidified O2 + early intubation preparation.
• Pulse oximetry is UNRELIABLE in CO poisoning — this is a favorite NLE distractor. The correct intervention is 100% O2 regardless of SpO2.

Key Points

• ELECTRICAL BURNS: Surface appearance grossly underestimates internal damage. Deep tissue injury is far greater than visible entry/exit wounds suggest.
• Electrical burns: Monitor for CARDIAC DYSRHYTHMIAS (continuous ECG) and MYOGLOBINURIA/RHABDOMYOLYSIS (dark, cola-colored urine = myoglobin from destroyed muscle). Myoglobinuria can cause acute kidney injury (AKI).
• For electrical burns with myoglobinuria: increase urine output target to 75–100 mL/hr to flush myoglobin through the kidneys.
• CHEMICAL BURNS: First action — BRUSH OFF any dry powder chemical before flushing. Then flush with COPIOUS WATER OR SALINE for 20–30 minutes. Do NOT attempt to neutralize the chemical with an opposite acid/base (this generates heat).
• INHALATION INJURY: Leading cause of EARLY DEATH in burn patients. Priority: 100% humidified oxygen for CO poisoning. Intubate EARLY before progressive airway edema closes the airway.
• Signs suggesting inhalation injury: facial burns, singed nasal hairs, carbonaceous (sooty/black) sputum, hoarseness, stridor, voice changes, history of fire in enclosed space.
• Carbon monoxide (CO) poisoning: CO binds to hemoglobin 200× stronger than O2, causing cellular hypoxia. Pulse oximetry is UNRELIABLE in CO poisoning (reads falsely normal). Give 100% O2 regardless of SpO2 reading.

Definitions

Section Title

5. Special Burn Types: Electrical, Chemical, and Inhalation

Common Mistakes

• Attempting to neutralize a chemical burn with an acid or base — this generates HEAT and worsens the injury. Always use copious water/saline flushing.
• Trusting pulse oximetry in CO poisoning — SpO2 reads falsely NORMAL because the oximeter cannot distinguish oxyhemoglobin from carboxyhemoglobin. Give 100% O2 regardless.
• Underestimating electrical burn severity based on small entry/exit wounds — internal damage is always far more extensive.
• Not monitoring ECG in electrical burn patients — dysrhythmias can be delayed and fatal.

Exam Tips

• Contrast table: Silver Sulfadiazine = no eschar penetration, leukopenia, sulfa contraindication. Mafenide = eschar penetration, painful, metabolic acidosis.
• NLE question: 'A burn patient develops metabolic acidosis. What topical agent is likely being used?' Answer: Mafenide acetate.
• Tetanus toxoid should always be included in burn care — do not overlook it in NLE options.
• IV route for opioids is non-negotiable during emergent phase due to poor tissue perfusion.

Key Points

• Silver Sulfadiazine (Silvadene/SSD): The CLASSIC topical antimicrobial for burns. Broad-spectrum antibacterial. Watch for TRANSIENT LEUKOPENIA (decreased WBC). Contraindicated in sulfa allergy, near-term pregnancy, and neonates/newborns. Does NOT penetrate eschar well.
• Mafenide Acetate (Sulfamylon): PENETRATES ESCHAR well — preferred for deep burns, cartilage areas (ears, nose). PAINFUL on application. Can cause METABOLIC ACIDOSIS by inhibiting carbonic anhydrase (which impairs bicarbonate regulation).
• Systemic antibiotics: Used ONLY for DOCUMENTED INFECTION — NOT given prophylactically to all burn patients (to prevent resistance).
• Tetanus prophylaxis: Give tetanus toxoid for all significant burns — burns are tetanus-prone wounds.
• IV Opioids (morphine, fentanyl): For burn pain management. Given IV during emergent phase. Titrate to effect.

Definitions

Section Title

6. Topical Burn Medications

Common Mistakes

• Giving silver sulfadiazine to a patient with sulfa allergy — it is CONTRAINDICATED.
• Expecting mafenide acetate to be comfortable — it is PAINFUL on application and must be explained to patients.
• Giving prophylactic systemic antibiotics to all burn patients — this promotes resistance. Systemic antibiotics are for DOCUMENTED INFECTION only.
• Forgetting tetanus prophylaxis for burn patients — burns are tetanus-prone wounds.

Exam Tips

• NLE distinguishes: Psoriasis = SILVERY SCALES + EXTENSOR surfaces + AUTOIMMUNE + NOT contagious. Eczema = WEEPING/PRURITIC + FLEXURAL areas + ATOPIC history.
• Cellulitis nursing priority: systemic antibiotics + elevation + MARK THE BORDER — this marking intervention is a classic NLE item.
• Herpes zoster: start antivirals within 72 hours. Isolation type depends on extent — localized = contact; disseminated or immunocompromised = contact + airborne.
• Honey-colored crusts in a child = IMPETIGO. Silvery plaques on elbows = PSORIASIS. Poorly demarcated warm red area = CELLULITIS. Vesicular rash following a line on one side = HERPES ZOSTER.

Key Points

• CONTACT DERMATITIS: Skin inflammation from irritant (irritant contact dermatitis) or allergen (allergic contact dermatitis). Presents with erythema, pruritus, and vesicles at the site of contact. Management: identify and REMOVE trigger, topical corticosteroids, antihistamines.
• ATOPIC DERMATITIS (Eczema): Chronic inflammatory skin condition associated with allergy, asthma, and allergic rhinitis (atopic triad). Intensely pruritic. Management: moisturizers/emollients (cornerstone), topical corticosteroids for flares, antihistamines, avoid scratching (causes secondary infection).
• PSORIASIS: Chronic AUTOIMMUNE disorder of accelerated epidermal cell turnover (days instead of weeks). Presents with WELL-DEMARCATED, RAISED, RED PLAQUES covered with SILVERY-WHITE SCALES on extensor surfaces (elbows, knees, scalp, sacrum). NOT contagious. Remitting-relapsing course. Management: topical corticosteroids, Vitamin D analogues (calcipotriene), coal tar, phototherapy (UVB), methotrexate, biologics (anti-TNF, anti-IL).
• CELLULITIS: Acute bacterial infection of the DERMIS and SUBCUTANEOUS TISSUE, usually Streptococcus or Staphylococcus (including MRSA) entering via skin break. Presents with ERYTHEMA, WARMTH, EDEMA, TENDERNESS, POORLY DEFINED BORDERS, possible fever and lymphangitic streaking. Management: systemic antibiotics (cephalexin, dicloxacillin; add MRSA coverage if suspected), ELEVATE the affected limb, warm compresses, MARK THE BORDER of redness with a pen to track progression.
• IMPETIGO: Highly contagious superficial bacterial infection (honey-colored crusts, common in children). Treatment: topical mupirocin or oral antibiotics; strict hygiene and isolation precautions.
• HERPES ZOSTER (Shingles): Reactivation of varicella-zoster virus along a DERMATOME. Painful vesicular rash, unilateral. Treatment: antivirals (acyclovir, valacyclovir) started within 72 hours of rash onset; pain management. Isolation: Contact + Airborne precautions for disseminated cases or immunocompromised patients.
• FUNGAL INFECTIONS (Tinea, Candidiasis): Treat with topical or systemic antifungals (clotrimazole, fluconazole); keep area dry; counsel on hygiene.

Definitions

Section Title

7. Dermatologic Disorders: Dermatitis, Psoriasis, Cellulitis, and Skin Infections

Common Mistakes

• Telling patients psoriasis is contagious — it is NOT contagious; it is an autoimmune condition.
• Using poorly defined borders to describe psoriasis — psoriasis has WELL-DEFINED borders; cellulitis has POORLY DEFINED borders.
• Not marking the margin of cellulitis erythema — marking the border is a KEY nursing action to monitor for progression.
• Forgetting to elevate the limb in cellulitis — elevation reduces edema and aids antibiotic delivery.
• Prescribing topical treatment alone for cellulitis — it requires SYSTEMIC antibiotics due to dermal/subcutaneous involvement.
• Applying herpes zoster standard precautions only — disseminated zoster requires AIRBORNE precautions in addition.

Exam Tips

• Emergent phase complication = SHOCK + HYPERKALEMIA. Acute phase = SEPSIS + HYPOKALEMIA + CURLING ULCER. Rehab phase = CONTRACTURE.
• Pressure garments for hypertrophic scars: worn approximately 23 hours per day, for up to 1–2 years as scar matures.
• Any burn patient with dark urine (cola-colored) = think MYOGLOBINURIA → increase fluids, monitor kidneys.
• Circumferential full-thickness burn + decreased distal pulse or decreased chest movement = ESCHAROTOMY needed.

Key Points

• BURN COMPLICATIONS by phase — Emergent: hypovolemic shock, hyperkalemia, hyponatremia, airway obstruction, AKI (from hypoperfusion). Acute: fluid overload, hypokalemia, infection/sepsis, Curling ulcer, paralytic ileus. Rehabilitation: contractures, hypertrophic scarring, body-image disturbance.
• CIRCUMFERENTIAL BURNS: Can cause compartment syndrome in extremities or restrict chest excursion. Require ESCHAROTOMY.
• INHALATION INJURY: Leading cause of early death in burns. Causes: CO poisoning, direct thermal injury, chemical injury to airways.
• ACUTE KIDNEY INJURY (AKI): From hypovolemia (emergent phase) or myoglobinuria (electrical burns). Monitor hourly urine output.
• PARALYTIC ILEUS: Gastrointestinal tract shuts down due to stress and fluid shifts; patient is kept NPO initially. Listen for bowel sounds before resuming feeds.
• CURLING ULCER: Stress ulcer in burn patients during acute phase; prevent with PPIs or H2 blockers.
• CONTRACTURES: Most common rehabilitation-phase complication. Prevent by: positioning in extension, ROM exercises, splinting, pressure garments.
• HYPERTROPHIC SCARRING: Excess scar tissue within wound margins; managed with pressure garments (worn ~23 hrs/day for months) and silicone sheets.
• SEPSIS from skin infections: Cellulitis can progress to lymphangitis, bacteremia, and sepsis. Necrotizing fasciitis is an emergency. Red flags: rapidly spreading erythema, fever, systemic signs.

Definitions

Section Title

8. Complications of Burns and Dermatologic Conditions

Common Mistakes

• Not recognizing that hypertrophic scars stay within wound margins while keloids extend beyond — a classic NLE distinction.
• Overlooking paralytic ileus in major burns — the bowel should be assessed before feeding is initiated.
• Not reporting rapidly spreading erythema in cellulitis as an emergency — this may indicate necrotizing fasciitis.
• Positioning burned extremities in FLEXION for patient comfort — this directly causes contractures. Always position in EXTENSION.

Exam Tips

• NLE patient teaching questions: 'Which instruction is CORRECT?' For psoriasis — 'This condition is not contagious and can be managed with treatment.' For cellulitis — 'Complete all antibiotic doses even if you feel better.' For burns — 'Set your water heater below 49°C.'
• Pressure garments: ~23 hours/day is the expected adherence. Removing ONLY for hygiene and dressing change is the correct instruction.
• For herpes zoster: within 72 HOURS of rash onset is the window for effective antiviral therapy.
• Zoster vaccine is for prevention of shingles in older adults — distinguish from varicella (chickenpox) vaccine for primary prevention.

Key Points

• BURN PREVENTION: Install and maintain smoke detectors. Set water heater temperature below 49°C (120°F). Kitchen and electrical safety. Avoid loose clothing near open flames.
• WOUND CARE TEACHING: Signs of infection (increased redness, purulent discharge, fever, foul odor). Proper dressing change technique. When to return to the hospital.
• NUTRITION: High-calorie, high-protein diet supports wound healing. Encourage compliance with vitamin and mineral supplements.
• PRESSURE GARMENTS: Must be worn approximately 23 hours a day; remove only for bathing and wound care. Explain that they prevent hypertrophic scars. Expect to wear for months to years.
• DERMATITIS: Identify and avoid triggers. Use emollients consistently. Apply topical corticosteroids as prescribed (avoid overuse — skin atrophy). Do not scratch — this causes excoriation and secondary infection.
• PSORIASIS: Emphasize this is a CHRONIC, REMITTING-RELAPSING condition — not curable but MANAGEABLE. It is NOT CONTAGIOUS. Address psychosocial burden and body image.
• CELLULITIS: Complete the FULL COURSE of antibiotics even when symptoms improve. Return immediately if redness spreads, fever develops, or red streaks appear (lymphangitis).
• HERPES ZOSTER: Antivirals must be started EARLY (within 72 hours). Pain can persist after rash heals (postherpetic neuralgia). Zoster vaccine (Shingrix) recommended for adults >50 years.

Section Title

9. Patient and Family Health Teaching

Common Mistakes

• Teaching patients with psoriasis that their condition is curable — it is NOT curable; it can be managed long-term.
• Telling cellulitis patients to stop antibiotics once they feel better — must complete the FULL course.
• Not discussing pressure garment adherence during rehabilitation — non-compliance leads to hypertrophic scarring.
• Forgetting the water heater temperature guideline (below 49°C/120°F) in burn prevention teaching — a common NLE patient education item.