TBSA / Rule of 9's
A 70-kg patient sustains burns to the entire left arm and anterior trunk in a house fire.
Calculate TBSA burned using the Rule of 9’s
Using the ABA consensus formula for NON-electrical burns (2 mL × kg × %TBSA), calculate the total IV fluid required in the first 24 hours.
Step 1: TBSA
Left arm = 9%
Anterior trunk = 18%
Total TBSA = 27%
Step 2: ABA formula
2 mL × 70 kg × 27
= 3780 mL total fluid in 24 hours
A patient arrives to the emergency department after a house fire with burns to the face and chest. The patient has singed nasal hairs, soot around the mouth, and hoarseness but is currently maintaining oxygen saturation at 95% on room air.
What is the priority nursing intervention?
Prepare for early airway management (administer high-flow oxygen and anticipate intubation).
Rationale:
Airway edema from inhalation injury can rapidly progress and obstruct the airway, so airway management takes priority over fluid resuscitation.
A patient with severe burn injuries is receiving IV morphine for pain control.
What is the priority assessment the nurse must monitor after administering this medication?
Respiratory rate and oxygenation
Rationale: Morphine is an opioid that can cause respiratory depression, which is the most serious adverse effect.
A patient develops anaphylactic shock after receiving IV antibiotics and now has:
hypotension
wheezing
urticaria
throat swelling
Which medication should the nurse administer first?
Epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis because it causes bronchodilation and vasoconstriction to reverse airway swelling and hypotension.
Shock is defined as inadequate what to the body’s tissues?
Oxygen delivery due to poor tissue perfusion.
Shock occurs when tissues do not receive adequate oxygen to meet metabolic needs.
A 90-kg patient has burns to the entire right leg and anterior trunk.
Calculate TBSA burned
Using the Parkland formula (4 mL × kg × %TBSA) calculate the total fluid for the first 24 hours
How many mL should be given in the first 8 hours?
Step 1: TBSA
Entire leg = 18%
Anterior trunk = 18%
Total TBSA = 36%
Step 2: Parkland formula
4 × 90 kg × 36
= 12,960 mL total in 24 hours
Step 3: First 8 hours
Half of total
12,960 ÷ 2 = 6,480 mL
A patient with 30% TBSA burns has the following assessment findings:
HR 128
BP 92/58
Urine output 15 mL/hr
Cool clammy skin
What is the priority nursing intervention?
Increase IV fluid resuscitation (Lactated Ringer’s).
Rationale: These findings indicate burn shock from hypovolemia, so restoring circulating volume is the priority.
A patient with partial-thickness burns is prescribed silver sulfadiazine cream.
Which patient history finding should the nurse report before administering this medication?
Sulfa allergy
Rationale: Silver sulfadiazine contains a sulfonamide, so it is contraindicated in patients with sulfa allergies.
A patient with septic shock remains hypotensive after receiving aggressive IV fluid resuscitation.
Which medication should the nurse anticipate administering next?
Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock and increases systemic vascular resistance to improve blood pressure and perfusion.
A patient with pneumonia develops:
HR 110
slightly decreased BP
cool clammy skin
decreasing urine output
Which stage of shock is the patient most likely experiencing?
Compensated shock
In early shock the body compensates with tachycardia and vasoconstriction, so BP may still appear near normal.
A 98-kg patient is admitted after a building fire with burns to:
Entire left arm
Chest
Abdomen
Back and buttocks
Calculate TBSA burned using Rule of 9’s
Using the Parkland formula (4 mL × kg × %TBSA) calculate the total IV fluid required in the first 24 hours
Calculate the pump rate for the first 8 hours
Calculate the pump rate for the next 16 hours
Step 1: TBSA
Left arm = 9%
Chest = 9%
Abdomen = 9%
Back and buttocks = 18%
Total TBSA = 45%
Step 2: Parkland formula
4 × 98 kg × 45
= 17,640 mL total in 24 hours
Step 3: First 8 hours
Half of total
17,640 ÷ 2 = 8,820 mL
Pump rate:
8,820 ÷ 8 = 1,102.5 mL/hr
Step 4: Next 16 hours
Remaining half:
8,820 mL
Pump rate:
8,820 ÷ 16 = 551 mL/hr
A burn patient receiving fluid resuscitation has the following hourly urine outputs:
Hour 1: 20 mL
Hour 2: 25 mL
Hour 3: 28 mL
The patient weighs 80 kg.
Based on burn resuscitation goals, what should the nurse do?
Increase IV fluid rate.
Rationale: Target urine output is ≥0.5 mL/kg/hr.
For this patient:
0.5 × 80 = 40 mL/hr
Since output is below goal, fluids should be increased.
A burn patient is receiving mafenide acetate topical therapy for infection prevention.
Which serious adverse effect should the nurse monitor for?
Metabolic acidosis
Rationale: Mafenide acetate can inhibit carbonic anhydrase and lead to metabolic acidosis, requiring monitoring of acid–base balance.
A patient in cardiogenic shock after an acute myocardial infarction has decreased cardiac output and poor tissue perfusion.
Which medication would the nurse expect to administer to increase cardiac contractility?
Dobutamine
Rationale: Dobutamine is an inotrope that increases cardiac contractility and improves cardiac output in cardiogenic shock.
A patient with septic shock develops:
hypotension
elevated lactate
decreased urine output
metabolic acidosis
Which stage of shock does this represent?
Progressive (uncompensated) shock
At this stage the body can no longer compensate, leading to hypotension and organ hypoperfusion.
A 75-kg adult sustains burns to:
entire right arm
anterior trunk
anterior right leg
The burns are non-electrical.
Calculate TBSA using the Rule of 9’s
Use the ABA formula (2 mL × kg × %TBSA) to determine total fluids for 24 hours
Calculate the pump rate for the first 8 hours
Step 1 — TBSA
Right arm = 9%
Anterior trunk = 18%
Anterior right leg = 9%
Total TBSA = 36%
Step 2 — ABA Formula
2 × 75 kg × 36
= 5400 mL total fluid in 24 hrs
Step 3 — First 8 hours
Half given in first 8 hrs:
5400 ÷ 2 = 2700 mL
Pump rate:
2700 ÷ 8
= 337.5 mL/hr
A burn patient develops brown, cola-colored urine after sustaining an electrical burn.
What complication should the nurse suspect and what is the priority intervention?
Suspect myoglobinuria from muscle breakdown (rhabdomyolysis).
Priority intervention: Increase aggressive IV fluids to prevent acute kidney injury.
Electrical burns can cause muscle destruction that releases myoglobin, which can damage the kidneys.
A burn patient with extensive injuries requires frequent wound debridement. The nurse administers IV fentanyl prior to the procedure.
What is the primary reason fentanyl is preferred in severe burn pain management?
Rapid onset and strong analgesic effect for severe acute pain
Rationale: Fentanyl is a potent opioid with rapid onset, making it useful for procedural pain such as dressing changes and debridement.
A patient in shock is receiving dopamine infusion. During monitoring the nurse notes tachycardia and dysrhythmias.
What is the priority nursing action?
Notify the provider and reassess the dopamine infusion rate.
Rationale: Dopamine can cause tachyarrhythmias, which are a significant adverse effect requiring intervention.
A patient in shock develops:
severe hypotension
liver failure
renal failure
worsening lactic acidosis
Which stage of shock is this?
Irreversible shock
At this stage organ damage is severe and recovery is unlikely even with treatment.
A 98-kg patient sustains burns to:
entire left arm
chest
abdomen
back and buttocks
The burn is non-electrical.
Calculate TBSA burned
Use the Parkland formula (4 mL × kg × %TBSA) to determine total fluid required in 24 hours
Determine the pump rate for the first 8 hours
Determine the pump rate for the next 16 hours
Step 1 — TBSA
Left arm = 9%
Chest = 9%
Abdomen = 9%
Back and buttocks = 18%
Total TBSA = 45%
Step 2 — Parkland Formula
4 × 98 kg × 45
= 17,640 mL total fluid
Step 3 — First 8 hours
Half given in first 8 hrs:
17,640 ÷ 2 = 8,820 mL
Pump rate:
8,820 ÷ 8
= 1,102 mL/hr
Step 4 — Next 16 hours
Remaining half:
8,820 mL
Pump rate:
8,820 ÷ 16
= 551 mL/hr
A patient with circumferential full-thickness burns of the leg reports increasing pain and numbness. Assessment reveals:
Pale toes
Decreased pedal pulses
Delayed capillary refill
Increasing swelling
What is the priority nursing action?
Notify the provider immediately for possible escharotomy.
Rationale: Circumferential burns can act like a tourniquet, restricting circulation and causing compartment syndrome. Immediate intervention is needed to restore perfusion.
A patient with major burns is prescribed silver nitrate dressings.
Which nursing intervention is most important when caring for a patient receiving this treatment?
Monitor electrolytes and maintain moist dressings
Rationale: Silver nitrate can cause electrolyte imbalances, and the dressing must remain continuously moist to maintain antimicrobial effectiveness.
A patient with severe burn shock has the following findings:
BP 82/48
HR 130
urine output 10 mL/hr
Which intervention should the nurse perform first?
A. Start norepinephrine
B. Administer lactated Ringer’s rapidly
C. Give morphine
D. Start antibiotics
B. Administer lactated Ringer’s rapidly
Rationale: Burn shock is a form of hypovolemic shock, so the priority intervention is rapid fluid resuscitation with isotonic fluids.
A nurse is assessing a patient with suspected septic shock.
Which finding is the earliest indicator of poor tissue perfusion?
A. Hypotension
B. Decreased urine output
C. Elevated lactate level
D. Cardiac dysrhythmia
C. Elevated lactate level
Lactate rises when tissues switch to anaerobic metabolism due to poor oxygen delivery, making it an early marker of shock.