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🫀 Physiological Adaptation · Lesson 10 of 10 · 8 min

Burns: The Parkland Formula and Neutropenic Fever

🔥 A 70 kg client with 40% burns needs 11.2 liters of fluid in 24 hours, and half of it in the first 8 hours from the time of the burn, not the time of arrival. The exam does the math and expects you to match it.

💡 Key idea

Parkland: 4 × kg × %TBSA, half in the first 8 hours from the burn. Expect hyperkalemia early, then hypokalemia. Inhalation signs mean intubate early. Neutropenic fever of 38 °C is an emergency.

🧠 Why it matters

BURN depth: superficial (red, painful, no blisters), partial thickness (blisters, moist, very painful) and full thickness (white, leathery or charred, painless at the center). Estimate area with the RULE OF NINES in adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%. PARKLAND FORMULA: 4 mL × kg × % total body surface area of lactated Ringer's over 24 hours, half in the first 8 hours FROM THE TIME OF INJURY and the rest over the next 16; titrate to a urine output of at least 0.5 mL/kg/hr (about 30 mL/hr), higher with electrical burns and dark urine. Many burn centers now start adults at 2 mL × kg × %TBSA and adjust to urine output, but the exam still teaches Parkland. The EMERGENT phase (first 24 to 48 hours) brings hypovolemia, HYPERKALEMIA from cell damage and hyponatremia; the ACUTE phase brings diuresis, hypokalemia and infection risk. Suspect INHALATION injury with facial burns, singed nasal hair, soot in the sputum, hoarseness or stridor, and prepare for early intubation; give 100% oxygen for carbon monoxide. Circumferential burns need escharotomy checks for circulation. Pain medication is given IV, never IM, because absorption is unreliable. NEUTROPENIC PRECAUTIONS for chemotherapy clients with an absolute neutrophil count below about 1,000 (per facility policy): private room, meticulous hand hygiene, no fresh flowers or plants, no raw or undercooked foods per policy, no rectal temperatures or suppositories, avoid crowds and sick visitors, and treat any temperature of 38.0 °C (100.4 °F) or higher as an EMERGENCY requiring cultures and antibiotics within an hour. THROMBOCYTOPENIA: once platelets fall under about 50,000, use bleeding precautions: a soft toothbrush, an electric razor and no injections where possible.

🏥 In the real world

🧮 The 70 kg client with 40% burns was burned at 1400 and arrives at 1600. Parkland: 4 × 70 × 40 = 11,200 mL. Half, 5,600 mL, is due by 2200, eight hours after the burn, which leaves only six hours to give it. The nurse sets the pump for the faster rate and watches the urine output. The exam's trap is starting the clock at arrival.

📌 Takeaways

  • Rule of nines: head 9, arms 9 each, legs 18 each, trunk 18 front and 18 back
  • Parkland: 4 mL × kg × %TBSA; first half in 8 hours from injury; titrate to 30 mL/hr urine
  • Neutropenia: no flowers, no rectal temps, fever of 38 °C needs antibiotics within an hour

📖 Terms in this lesson

Parkland formula: Burn fluid resuscitation: 4 mL × kg × percent of body surface burned over 24 hours, half in the first 8 hours from the injury.

Antiemetics (ondansetron, metoclopramide): Ondansetron blocks serotonin to prevent chemotherapy and surgical nausea and can prolong the QT interval; metoclopramide empties the stomach but carries a boxed warning for irreversible tardive dyskinesia, so it is limited to 12 weeks and stopped for abnormal movements.

Filgrastim and epoetin alfa: Filgrastim raises neutrophils after chemotherapy, causes bone pain and is not given within 24 hours of a dose, while epoetin alfa raises hemoglobin in kidney disease but raises blood pressure and clot risk, so it is held when hemoglobin passes 10 to 11 g/dL.

Methotrexate: A folate blocker for cancer, rheumatoid arthritis and psoriasis that suppresses the marrow and damages the liver, lungs and mouth lining; weekly doses taken daily by mistake are fatal, so confirm the schedule, give folic acid or leucovorin rescue as ordered, and prevent pregnancy.

✅ Test yourself

A client weighing 80 kg has burns over 30% of the body. Using the Parkland formula, how much fluid should be given in the first 8 hours after the burn?
  1. 9,600 mL
  2. 19,200 mL
  3. 4,800 mL
  4. 2,400 mL

Answer: C · 4,800 mL

4 × 80 × 30 = 9,600 mL over 24 hours; half, 4,800 mL, is given in the first 8 hours.

A client with facial burns has singed nasal hairs and a hoarse voice. What is the priority nursing concern?
  1. Infection of the facial burns
  2. Pain control
  3. Impending airway obstruction
  4. Fluid overload

Answer: C · Impending airway obstruction

These signs predict airway edema; early intubation may be needed before swelling closes the airway.

A client receiving chemotherapy has an absolute neutrophil count of 400 and a temperature of 38.3 °C (100.9 °F). What is the nurse's priority action?
  1. Encourage oral fluids and rest
  2. Give acetaminophen and recheck in 4 hours
  3. Obtain cultures and notify the provider
  4. Apply a cooling blanket

Answer: C · Obtain cultures and notify the provider

Fever in a neutropenic client is a medical emergency; sepsis can develop rapidly, so cultures and antibiotics are started within an hour.

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