👤 By the CinnaRN Clinical Content Team🕐 Updated 2026-08-23🏷️ Physiological Adaptation🔖 Free to read, print, and share
Also known as: burn injury · burns · rule of nines · TBSA · thermal burn · fluid resuscitation burn
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Use this quick-reference guide to spot, treat, and prevent Burns and Rule of Nines on the NCLEX. Keep it handy during review and on exam day!
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📒 The 1-minute cheat sheet
📌 9s Adult
Head 9%, each arm 9%
Each leg 18%, front/back trunk 18%
Perineum 1%
✅ Priority
Airway: facial burns, soot, stridor
Parkland: LR for fluid resusc
Half fluid in first 8 hrs
🧪 Monitor
Urine 30–50 mL/hr = adequate
Watch hyperkalemia early
🚩 Report
Circumferential burn → compartment synd
📚 Burns and Rule of Nines — full study notes
The cheat sheet above is your quick recall card. These notes go deeper — what it is, what to do first, what must be reported, and what to teach.
Burns destroy skin and tissue from heat, chemicals, electricity, or radiation, causing massive fluid shifts, infection risk, and possible airway compromise. Severity is judged by depth (superficial, partial-thickness, full-thickness) and by the percent of total body surface area (TBSA) burned, estimated with the Rule of Nines. In adults the Rule of Nines assigns 9% to the head, 9% to each arm, 18% to each leg, 18% to the anterior trunk, 18% to the posterior trunk, and 1% to the perineum. The Parkland formula guides fluid resuscitation in the first 24 hours.
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Key points
Understand these first
Rule of Nines (adult): head 9%, each arm 9%, each leg 18%, front trunk 18%, back trunk 18%, perineum 1%.
The first 24 to 48 hours is the emergent (fluid shift) phase with capillary leak, third-spacing, and hypovolemic burn shock.
Inhalation injury is suspected with facial burns, singed nasal hair, soot in mouth, hoarseness, or carbonaceous sputum.
Full-thickness (third-degree) burns appear dry, leathery, white or charred, and are painless because nerve endings are destroyed.
Circumferential burns to the chest or extremities can cause compartment syndrome and may require escharotomy.
Parkland formula: 4 mL lactated Ringer's x kg x %TBSA; give half in the first 8 hours from time of injury.
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Nursing priorities
What to do, in order
Assess and secure the airway first; anticipate early intubation if inhalation injury is present before edema closes the airway.
Administer warmed lactated Ringer's per Parkland formula and titrate to urine output of 30 to 50 mL/hr (about 0.5 mL/kg/hr).
Remove constricting clothing and jewelry; stop the burning process and cover wounds with clean dry dressings.
Provide IV opioid analgesia (not IM or SubQ) because absorption is unreliable during fluid shifts.
Maintain strict aseptic technique, protective isolation, and high-calorie high-protein nutrition to support healing.
Urine output below 30 mL/hr or rising specific gravity indicates inadequate fluid resuscitation; escalate now.
Cherry-red skin or altered mental status suggests carbon monoxide poisoning; give 100% oxygen.
Never apply ice to burns or give IM/SubQ medications; never break blisters at the bedside.
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Labs & values
Numbers to know
Potassium: elevated early from cell lysis (normal 3.5 to 5.0 mEq/L)
Hematocrit: elevated early from hemoconcentration (normal 36 to 50%)
Carboxyhemoglobin: elevated with CO exposure (normal less than 5%)
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Patient teaching
What patients must know
Keep healed burn areas out of direct sun and use sunscreen; new skin burns easily.
Perform range-of-motion exercises and wear pressure garments to prevent contractures and scarring.
Report increasing redness, foul drainage, or fever as signs of wound infection.
❓ Burns and Rule of Nines: NCLEX FAQs
What are the priority nursing interventions for Burns and Rule of Nines?
Assess and secure the airway first; anticipate early intubation if inhalation injury is present before edema closes the airway. Administer warmed lactated Ringer's per Parkland formula and titrate to urine output of 30 to 50 mL/hr (about 0.5 mL/kg/hr). Remove constricting clothing and jewelry; stop the burning process and cover wounds with clean dry dressings. Provide IV opioid analgesia (not IM or SubQ) because absorption is unreliable during fluid shifts.
What are the warning signs of Burns and Rule of Nines a nurse must report?
Hoarseness, stridor, drooling, or increasing facial edema signals impending airway obstruction; intubate immediately. Urine output below 30 mL/hr or rising specific gravity indicates inadequate fluid resuscitation; escalate now. Cherry-red skin or altered mental status suggests carbon monoxide poisoning; give 100% oxygen. Never apply ice to burns or give IM/SubQ medications; never break blisters at the bedside.
What do I need to know about Burns and Rule of Nines for the NCLEX?
Rule of Nines (adult): head 9%, each arm 9%, each leg 18%, front trunk 18%, back trunk 18%, perineum 1%. The first 24 to 48 hours is the emergent (fluid shift) phase with capillary leak, third-spacing, and hypovolemic burn shock. Inhalation injury is suspected with facial burns, singed nasal hair, soot in mouth, hoarseness, or carbonaceous sputum. Full-thickness (third-degree) burns appear dry, leathery, white or charred, and are painless because nerve endings are destroyed.
What patient teaching is important for Burns and Rule of Nines?
Keep healed burn areas out of direct sun and use sunscreen; new skin burns easily. Perform range-of-motion exercises and wear pressure garments to prevent contractures and scarring. Report increasing redness, foul drainage, or fever as signs of wound infection.
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Quick Tip
Rule of Nines (adult): head 9%, each arm 9%, each leg 18%, front trunk 18%, back trunk 18%, perineum 1%.