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01.12 Nursing Care and Pathophysiology for Rhabdomyolysis

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Overview

Pathophysiology: Injury to the skeletal muscle occurs. This damage leads to the release of intracellular material into the blood circulation, which can become toxic. 

  1.  Rhabdomyolysis
    1. Skeletal muscle break down
    2. Kidneys are most affected

Nursing Points

General

  1. Injury occurs
    1. Trauma
      1. Burns
      2. Compartment syndrome
    2. Substance abuse
    3. Medications (statins)
    4. Infections
    5. Excessive exercise
    6. Prolonged immobilization
  2. Breakdown of skeletal muscle fibers
  3. Components from cells leak into blood
    1. Creatinine kinase (CK) –> 10 times elevated level in blood
    2. Myoglobin
    3. Potassium
    4. Phosphorus
  4. Kidneys blocked –>renal tubule ischemia –> necrosis –> renal failure!
    1. Low or no urine output
    2. Dark urine
  5. Electrolyte imbalance affects heart rythm
  6. Complication = ORGAN FAILURE
  7. Goal of treatment = Preserve organ function!

Assessment

  1. Presentation
    1. Weakness
      1. Breakdown of muscle fibers
    2. Swelling
      1. Leakage of intracellular components –> electrolyte imbalance –> fluid shifting
    3. Dark colored urine
      1. Kidneys are obstructed by myoglobin –> decreased urine output
    4. Confusion
      1. Toxins in blood –> effect brain
    5. Arrythmia (telemetry) –> electrolyte imbalance

Therapeutic Management

  1. Protect kidneys
    1. Normal saline infusions –> flush kidneys
    2. Diuretics –> reduce swelling by increasing urine output
    3. Dialysis –> clean toxins from blood
  2. Allow patient to rest muscles
  3. Monitor electrolytes and CK level

Nursing Concepts

  1. Elimination –> decreased with rhabdomyolysis
  2. Fluid & Electrolyte Balance –> imbalance with rhabdomyolysis
  3. Lab Values –>CK levels
  4. Cellular Regulation –> damage to muscle cell membranes, leakage of contents, imbalance of regulation

Patient Education

  1. Monitor urine color and amount
  2. Begin activity slowly and increase over time
  3. Seek help after trauma
  4. Elders –> plan for future falls
    1. Family check on
    2. Phone in pocket
  5. Avoid drugs

Reference Links

Study Tools

Video Transcript

Hey guys! Welcome to the lesson on rhabdomyolysis where I will help you understand what rhabdo is, what causes it, and how to manage it. Let’s explore what happens in rhabdo. 

So, rhabdomyolysis is caused some type of injury that causes the skeletal muscle to break down. The injury may be an actual trauma like in this picture this patient’s arm was crushed and developed compartment syndrome, which in turn resulted in broken down muscles. Check out the lesson on compartment syndrome for more details. Other causes of rhabdo include substance abuse, medications like statins, or severe infections with extreme inflammation and muscle breakdown. I have actually had patients admitted for excessive exercise that put them into rhabdo. Another common cause that I have see is prolonged immobilization where elders fall or someone takes too many drugs and is passed out and on the floor for a few days before someone finds them, causing their muscles to break down. 

When the muscle cells break down, everything inside the cell is leaded into the bloodstream. Let’s pretend this is a patient’s leg and they went to a really extreme spinning class and severely overworked their leg muscles. This is a picture of a muscle cell inside of the leg. Creatinine kinase, myoglobin, potassium, and phosphorus are all components within the cell, so when that cell is destroyed, they will all leak out into the bloodstream. 

So, after the muscle cells break down and the components are leaked into the bloodstream, those components are going to affect the rest of the body. The kidneys are going to be affected the most because the myoglobin blocks the renal tubules making it hard for them to get oxygen from blood. They will eventually die without treatment and renal failure will occur. The patient may have low urine output or none at all. The brain is affected as well because of the toxins in the blood reaching the brain causing confusion. The electrolyte imbalance from the cellular leakage can lead to irregular heart rhythms. The biggest complication and end result of rhabdo is organ failure. 

The patient with rhabdo is going to present with weakness, swelling, dark colored urine, low or no urine output, and confusion. It depends on what caused the rhabdo, for example a patient like in this picture that over exerted themselves in exercise will have a lot of pain and swelling in their legs. A patient that was lying in one spot for a long period of time may just be super confused. This is why it is important to assess our patients thoroughly. 

We will be monitoring our patients lab values, which will show increased CK, myoglobin, potassium, and phosphorus. The normal ranges will depend on the policies of the organization that your are working in, however here are some guidelines for normal ranges to go off of. Potassium is usually around 3.5 to 5. Phosphorus is 2.5 to 4.5. Creatinine kinase levels vary from 22 to 198, and myoglobin levels may be zero, or up to 85. Here is our patient in rhabdo with a foley catheter and an I & O sheet  so that we may monitor their output to ensure their kidney function is improving with treatment. The patient may be put on continuous cardiac monitoring telemetry to watch for arrhythmias. And of course, we want to assess the patient’s pain level and try to keep them comfortable. 

So we want to keep our patient’s kidneys working. We will administer normal saline IV infusions to flush the kidneys. Diuretics may be given to reduce any swelling in the body and to increase their urine output. Dialysis may be necessary to clean toxins from the blood if the kidneys are failing to do so. It’s important that we let our patients rest their muscles to prevent any further injury. 

You will want to let your patient know to keep an eye on their urine color and amount, and to start activity slowly and increase over time. They should seek help right away after any trauma that occurs to their body. If your patient is an elder, help them to plan for future fall incidents. They might have a family member check on them daily, a cell phone they keep in their pocket at all times, or even a life alert button that they can press if they fall. This could prevent them from lying in a spot for many days. Patients that use drugs should be advised to stop to prevent further damage to their body. 

Our priority nursing concepts for rhabdomyolysis are elimination, cellular regulation, and fluid and electrolyte balance. 

Let’s review the key points about rhabdomyolysis. So some type of injury occurs to the muscle like trauma, immobility, substance abuse, or excessive exercise, causing the muscle to breakdown. The broken down muscle cells allow CK, myoglobin, potassium, and phosphorus to leak into the bloodstream. Lab draws can monitor how much of these components are in the blood. The myoglobin blocks the kidneys leading to dark urine and decreased or no urine output. We manage rhabdo with IV fluids to flush the kidneys. We monitor the output, and keep an eye on the lab values we just mentioned. We should educate our patients to slowly become active again, and watch their urine color and amount. If they have an injury, they should see a doctor so that it does not progress into rhabdo. When caring for elders, it’s helpful to plan for falls because it is common and scary if they don’t have help. They might have a family member check on them daily or maybe a phone in their pocket at all times. And lastly, we should encourage our patients to stop or avoid drug usage. 

I hope you have a better understanding of what rhabdo is and how we manage it. Now go out and be your best self today, and as always, happy nursing!

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