Last updated on January 4th, 2023 at 09:38 am
Rhabdomyolysis Nursing Care Plans Diagnosis and Interventions
Rhabdomyolysis NCLEX Review and Nursing Care Plans
Rhabdomyolysis is a complex condition characterized by the rapid destruction of an already injured skeletal muscle. Injury can cause a disruption to the integrity of the skeletal muscles which may lead to the release of intracellular contents including potassium, creatinine kinase (CK), phosphate, myoglobin, and urate into the extracellular compartments.
In effect, the disruption in the levels of these chemicals in the blood stream and other extracellular spaces can cause serious and life-threatening complications.
About 26,000 cases of rhabdomyolysis are reported annually in the United States alone.
In adults, the most common causes are crush injuries, alcohol and drug abuse, and overexertion.
Signs and Symptoms of Rhabdomyolysis
The signs and symptoms of rhabdomyolysis are non-specific.
The clinical manifestations are often reliant on the cause of the disease. Historically, rhabdomyolysis is known to have a triad of symptoms which include myalgia, weakness, and myoglobinuria.
However, this idea is not anymore relied on as only less than 10% of cases showcased the presence of all these symptoms.
The following are the common signs and symptoms associated with rhabdomyolysis:
- Muscle pain, tenderness, and/or swelling
- Bruising
- Weakness
- Tea-colored urine which may suggest myoglobinuria
- Fever
- Malaise
- Nausea and vomiting
- Confusion, agitation
- Delirium
- anuria
Causes of Rhabdomyolysis
The causes of rhabdomyolysis are often classified into traumatic and non-traumatic reasons.
Traumatic causes directly lead to muscle injury while the non-traumatic causes indirectly cause muscle injury.
- Traumatic Causes
- crush injuries including fall, vehicular accident, or building collapse.
- Prolonged muscle compression such as immobility due to medical conditions and frailty in old age group
- Electrical shock
- Severe burn
- Lightning strike
- A bite from a venomous snake
- Non-traumatic Causes
- Alcohol and drug use
- Muscle strain
- Use of antipsychotics and statins in high doses. The relationship between rhabdomyolysis and statins have long been discussed and studied. Data suggest that there is a real risk of developing rhabdomyolysis, although rare, in prolonged use of statins in high doses.
- Hyperthermia or heat stroke
- Seizures
- Diabetic Ketoacidosis
- Myopathy
- Viral infections such as HIV and AIDS
- Bacterial infections
Complications of Rhabdomyolysis
Early complications of rhabdomyolysis may include the following:
- Hyperkalemia – Potassium is a major intracellular electrolyte. Destruction of skeletal muscle cells hence increases potassium in the blood stream causing hyperkalemia.
- Hypocalcemia – Hypocalcemia occurs due to the release of phosphate from muscle breakdown. The high phosphate level triggers the body to deposit calcium on the injured skeletal muscle cells.
- Hepatic Inflammation – This complication occurs in 25% of cases of rhabdomyolysis. Liver involvement in rhabdomyolysis is believed to be precipitated by proteases.
- Cardiac arrhythmia – this complication is caused by hyperkalemia.
- Cardiac arrest – hyperkalemia can also lead to cardiac arrest.
Late complications are as follows:
- Acute renal failure – ARF occurs in 15% of cases of rhabdomyolysis. It is the most serious of complications as it is highly related to morbidity and mortality. Rhabdomyolysis can lead to ARF due to the following reasons:
- Precipitation of myoglobin
- Toxic effect of chelatable iron on renal tubules
- Hypovolemia
- Disseminated intravascular coagulation – DIC is also a possible complication of rhabdomyolysis. It is usually worse on the 3rd to 5th day of presentation.
Early or Late complications:
- Compartment syndrome – may result from the direct or indirect injury to the muscles. Treatment to release pressure should be considered when the pressure reaches 30mmHg.
Diagnosis of Rhabdomyolysis
Rhabdomyolysis may be difficult to diagnose as signs and symptoms are often non-specific.
A high index of suspicion is necessary for the early identification of the disease.
- History and physical examination – Medical history and physical examination will need to focus on the presence of risk factors, muscle injuries and trauma. Neuromuscular exam focusing on the lower extremities to check for pulses, sensation, color, muscle power and size once completed is very informative for the diagnosis of this condition.
- Plasma CK levels – This laboratory test is a gold standard in diagnosing rhabdomyolysis. At the moment there is no general rule of what the cut off is in CK levels is used. However, most physicians follow the rule of CK levels becoming 5 times more than the normal levels. CK level is also predicative of possible acute renal failure.
Treatment of Rhabdomyolysis
Rhabdomyolysis can occur due to several reasons.
However, no matter what the etiology is, the primary focus of rhabdomyolysis treatment is prevention of acute renal failure.
- Fluid management. Hydration is very crucial in the treatment of rhabdomyolysis. Fluid management through increased oral fluid intake and intravenous therapy promotes normal blood volume level in the body and also prevents acute renal failure from occurring.
- Hypocalcemia treatment. This should not be given unless it causes any significant problems. This is to prevent further occurrence of hypercalcemia which is normal in the recovery phase of the disease.
- Hemodialysis. This treatment may sometimes be necessary to promote normal chemicals and electrolytes level in the blood stream. It also allows the kidneys to recuperate from the extra work load it received at the height of the disease process.
- ICU care. Care in the intensive care unit is often required in elderly patients with rhabdomyolysis. Constant monitoring of vital signs and of fluid volume is important to assess the progress of the disease.
Rhabdomyolysis Nursing Diagnosis
Rhabdomyolysis Nursing Care Plan 1
Nursing Diagnosis: Hyperthermia related to the inflammatory process of Rhabdomyolysis as evidenced by temperature of 39 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
| Rhabdomyolysis Nursing Interventions | Rationales |
| Assess the patient’s vital signs at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the fever-reducing drugs administered. |
| Remove excessive clothing, blankets and linens. Adjust the room temperature. | To regulate the temperature of the environment and make it more comfortable for the patient. |
| Administer the prescribed anti-pyretic medications. | Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. Aspirin helps alleviate fever and reduces pain due to its anti-inflammatory property. Caution is recommended in the use of aspirin as it is known to cause Reye’s syndrome. |
| Offer a tepid sponge bath. | To facilitate the body in cooling down and to provide comfort. |
| Elevate the head of the bed. | Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Rhabdomyolysis Nursing Care Plan 2
Nursing Diagnosis: Fluid Volume Deficit related to injury of skeletal muscles due as evidenced by temperature of 39.0 degrees Celsius, tea-colored urine output, nausea and vomiting, profuse sweating, and blood pressure of 89/58.
Desired Outcome: Within 24 hours of nursing interventions, the patient will be able to achieve a normal fluid balance with absence of fever.
| Rhabdomyolysis Nursing Interventions | Rationales |
| Commence a fluid balance chart, monitoring the input and output of the patient. | To monitor patient’s fluid volume accurately and effectiveness of actions to reverse dehydration. |
| Start intravenous therapy as prescribed. Encourage oral fluid intake as tolerated. | To replenish the fluids lost from profuse sweating, and to promote better blood circulation around the body. |
| Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside. | To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. |
| Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed. | Sodium is one of the important electrolytes that are lost when a person is sweating. Hyponatremia or low serum sodium level may cause brain swelling. |
Rhabdomyolysis Nursing Care Plan 3
Nursing Diagnosis: Acute Pain related to the inflammatory process of rhabdomyolysis as evidenced by pain score of 10 out of 10, verbalization of muscle pain, guarding sign on the painful areas, irritability, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
| Rhabdomyolysis Nursing Interventions | Rationale |
| Administer prescribed medications that alleviate the symptoms of muscular pain. | Pain medications such as anti-inflammatory drugs are given for pain relief in patients with rhabdomyolysis. |
| Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication. | To monitor effectiveness of medical treatment for the relief of pain. The time of monitoring of vital signs may depend on the peak time of the drug administered. |
| Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. | To increase the oxygen level and achieve an SpO2 value within the target range. |
| Place the patient in complete bed rest. Educate patient on deep breathing exercises, and relaxation techniques. | To promote healing and recovery. |
Rhabdomyolysis Nursing Care Plan 4
Nursing Diagnosis: Fatigue related to injury of skeletal muscles as evidenced by body malaise, overwhelming lack of energy, verbalization of tiredness and generalized weakness, lack of appetite, and shortness of breath upon exertion
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
| Rhabdomyolysis Nursing Interventions | Rationales |
| Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try. | To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance. |
| Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep. | To gradually increase the patient’s tolerance to physical activity. |
| Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room. | To allow the patient to relax while at rest. To allow enough oxygenation in the room. |
| Refer the patient to dietitian and physiotherapy / occupational therapy team as required. | To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity and improving nutritional intake / appetite. |
More Nursing Diagnosis for Rhabdomyolysis
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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