Question

Activities Required Prior to Simulation: Pre-Simulation Questions 1. Discuss conditions that predispose patients to rhabdomyolysis. 2. What are the clinical findings and signs and symptoms of rhabdomyolysis? 3. What are the nursing responsibilities related to the care of the patient with rhabdomyolysis?

Answer 1

Answer 1.

Rhabdomyolysis is a condition characterized by the destruction of the skeletal muscle fibers leading to the release of myoglobin into the bloodstream.  

Conditions that predispose to rhabdomyolysis:

1. Physical:
   1. Trauma ( Crush injury)
   2. Exercise exercise
   3. Tetanus ( muscle spasm)
   4. Seizures ( Intense muscle contraction leading to damage to the muscle fibres)
   5. Prolong immobilization
   6. Major artery occulsion
2. Non physical:
   1. Genetic defects in glycogenolysis and glycolysis
   2. Infection leading to myositis ( Dengue, Legionella, Malaria)
   3. Increase body temperature ( Increase in ambient temperature, Narcoleptic malignant syndrome)
   4. Metabolic and electrolyte disorders
   5. Drugs and toxins ( Propofol, ethanol, Ecstasy, Amphetamine overdose)
   6. Autoimmune disorder ( Polymyositis)

All these condition leads to:

1. Direct injury to the cell membrane
2. Muscle hypoxia - this leads to loss of ATP
3. Electrolyte disturbance - disturbs the Na+ / K+ pump

The overall effect is disruption of the muscle fibre destruction. This leads to release

• of K+ and Phosphorus
• Myoglobin
• Creatinine Kinase

This leads to renal tubular obstruction.

Answer 2:

Symptoms of rhabdomyolysis:

1. Muscle pain
2. Generalized weakness
3. Dark urine

Signs of rhabdomyolysis:

1. Muscle tenderness
2. Soft tissue swelling
3. Increase body temperature
4. Bruising of skin

Answer 3:

The nursing responsibilities related to rhabdomyolysis are as follows:

1. Maintain input and output.
2. Monitor urine specific gravity - This is the measure of the kidney's capacity to concentrate urine. Reduction in the specific gravity means loss of urine concentrating capacity of the kidney. This is suggestive of renal failure.
3. Monitor the patient's weight - this also give idea about the fluid status in the body. An increase in the body weight by 0.5 kg/ day, is suggestive of fluid retention.
4. Monitor edema
5. Ausculate the patient's lungs - Presence of new onset crepitation / rales suggest development of pulmonary edema.
6. Avoid nephrotoxic drug.
7. The patient's bed should have side-rails. To prevent injury to the patient as these patient can become confused ( due to involvement of the CNS)
8. Monitor - renal functions ( Blood urea nitrogen and Sr. Creatinine) and serum electrolyte.
9. Insert a folley's catheter. This allows accurate measurement of urinary output.
10. Administer the patient diuretics - this can be given in the anuric or oligouric phase to obtain urine output.
11. Antihypertensive can be give to reduce the blood pressure.
12. Calcium channel blockers help to reduce the calcium influx into the kidney, improve cell integrity.
13. The needs to be prepared for hemodialysis if
    1. Conservative approach fail
    2. No urine output
    3. Hyperkalemia
    4. Uremic encephalopathy
    5. Metabolic acidosis