careplan for rhabdomylosis/ARF !

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Usually I am pretty good at figuring things out but this has me stumped, mainly because it is not mentionied in my textbooks!

I get that rhabdomylosis is r/t skeletal muscle breakdown, either from acute traumatic injury, compartment syndrome, overexertion, and/or drug use. (I think drug use is the main reason in this case, although there was some exertion too)

And I get the pathophys of ARF.

But I can't figure out what to DO with this patient.

I have to have a very specific, hour by hour plan for care for this patient. I have the teaching part figured out--s&s of rhbdo..to watch for in the future.

But diagnosis will need to be r/t ARF, its oliguric so I am guessing FVE will work but I don't know til I see the pt. (Have to have two dx's before I get there tomorrow!!) Hyperkalemia is of course part of the picture, and that mostly involves monitoring tele and LOC, pulse etc.

All I can figure out now is q4h assessments. Repositioning since pt is bedrested and likely fatigued. Monitor foley, I&O, tele and labs. Incentive spirometer since bedrested. And teaching.

That is surely not enough to get thru a whole shift! No major meds to speak of, no fluids running--just a hep lock. No O2 running.

anyone who can shed some light on this welcomed to contribute. What does a patient look like in this condition? What on earth are nursing interventions or at least diagnosis??

I am sorry to ask for help. Like I said, I usually do pretty good with this but I have no clue at all this time. I really just need a jumping off part and then I can swim with it.

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Specializes in Gerontological, cardiac, med-surg, peds.

The treatment plan for rhabdomyolysis will depend on the effects of the muscle breakdown on the patient. Of course, you want to immediately discontinue all precipitating agents (statin drugs, toxins, etc.) and treat the underlying causes (dehydration, trauma, infection, etc.). The patient may need dialysis. Vigorous hydration with several liters of normal saline (to rapidly eliminate the myoglobin from the kidneys) is the initial therapy for rhabdomyolysis.

The priority with rhabdomyolysis is prevention of injury to the kidneys (IMHO, Risk for Renal Injury r/t possible necrosis of kidney tubules secondary to exposure to myoglobulin released into the circulation from injured muscle tissues). The nurse needs to carefully monitor kidney function (BUN/ creatinine, strict I & O, etc.). Another high priority: Risk for Injury (sudden cardiac death) or Risk for Decreased Cardiac Output r/t possible life-threatening cardiac dysrhythmias/ cardiac arrest secondary to hyperkalemia. This is due to the effects of hyperkalemia secondary to release of large amounts of potassium into the circulation from damaged (lysed) muscle cells and inability of the body to excrete the excess potassium due to acute renal failure. The nurse needs to closely monitor cardiac function and keep close tabs on the serum potassium level. Hyperkalemia is the most dangerous of all electrolyte imbalances, as it may cause life-threatening cardiac dysrhythmias and cardiac arrest.

Some good information here:

http://www.findarticles.com/p/articles/mi_m0NUC/is_6_23/ai_111696992

http://www.rhabdomyolysis.org/rhabdomyolysis.html

http://www.rhabdomyolysis.org/pages/treatments_rhabdo.html

http://www.emedicine.com/EMERG/topic508.htm

Actual careplan on rhabdomyolysis, but must be a subscriber:

http://www.careplans.com/pages/lib/lib_get.asp?id=390

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Oh wow thank you!! I totaly appreciate your help! Thank you so so so much! :) :)

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Specializes in Gerontological, cardiac, med-surg, peds.
Coopergrrl said:
Oh WOW! thank you!! I totaly appreciate your help! Thank you so so so much! ? ?

Glad to be of assistance ? Hope your clinical went well and your patient is doing better.

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I may be too late to help with your careplan but for future reference you will want to monitor the myoglobin levels they can reach out rageous proportions like 6,579 in such case you would have a nursing diagnosis of

acid base imbalance related to elevated myoglobin and you would treat it with iv fluids with sodium bicarb to buffer the kidneys and correct the acidosis- monitor abgs for metabolic acidosis ,

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VickyRN said:
Glad to be of assistance ? Hope your clinical went well and your patient is doing better.

It turned out that the patient had so many social/mental health issues etc that I spent more time dealing with inappropriate comments and requests LOL. (I did however learn from pt just how to make a bong out of an incentive spirometer:uhoh3: ) I concentrated on the fluid volume excess which was getting to be a big issue when I left the floor. They were running D5W w/ HCO3 @ 100/hr to alkalinize urine...great theory but output went down pretty drastically so I worry he was going to become systemically alkaline...although being acidotic already...I don't know, maybe it would balance him out. Anyway, tele got d/c'd for some unknown reason while I was at lunch, shift changed before I got back and then my co-assigned nurse was so busy with her other patients it was hard to figure our just why. K+ got normal but with such low output and then now with the bicarb I'd be scared.

He got a bit petulant after being told by the charge nurse more than once that he'd have to be more quiet, take his phone off speaker and stop swearing since he'd got a roomate LOL He then pouted and wanted to go home, and wanted me to take out his foley and wanted a complete bed bath. Oh what a night LOL.

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burn out said:
I may be too late to help with your careplan but for future reference you will want to monitor the myoglobin levels they can reach out rageous proportions like 6,579 in such case you would have a nursing diagnosis of

acid base imbalance related to elevated myoglobin and you would treat it with iv fluids with sodium bicarb to buffer the kidneys and correct the acidosis- monitor abgs for metabolic acidosis ,

yes they added bicarb to his IV fluids. His labs were astronomically high. Like I posted above tho, with oliguric ARF wouldn't the fluids increase the pressure? I am not great with fluid/electrolyte stuff but trying to make him alkaline w/ the bicarb when he is putting off maybe 5 - 10 ml/hr might just run his ABGs the other way, right? Anyway, they were debating dialysis and unless he miraculously got better in the last few hours, I am sure he is being dialyzed by now.

Its kind of a shame that only going once a week I never get good followup to see what happens after to these patients.

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I was looking on a careplan for Rhabdomylosis and this helped tremendously! Thanks

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