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Example Care Plan_Rhabdomyolysis (Cheat Sheet)
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Hi everyone. Today's nursing care plan we're going to be discussing rhabdomyolysis. So, let's get started. First, we're going to talk about the pathophysiology. So, rhabdomyolysis is when skeletal muscle is destroyed and their intracellular contents, in particular myoglobin, is leaked into the bloodstream. Some nursing considerations are to ensure proper fluid resuscitation, recording the patient's I & O, monitoring lab values, replacing electrolytes as per order, monitor for signs of compartment syndrome, and any discharge planning on prevention. Desired outcomes: the patients will remain adequately hydrated, electrolytes are within normal limits, patients will have proper diet, and use caution when exercising to avoid any sort of further skeletal muscle breakdown and if medication was the cause that the patient will have other options and interventions to use.
So, if we're going to go over the care plan, we're going to be going over some of the subjective data, things that you're going to see with the patient and objective data. So, some subjective data, one of the major ones with rhabdo is going to be some cramp in the legs and some generalized weakness. Also, a very classic sign is going to be very dark colored urine, and I'm talking Cola color or tea color is what you'll see with this patient. That's because of the breakdown of those proteins. You'll also see some nausea, tender muscles, vomiting, fever, edema, and possible skin changes, which may even look necrotic on some patients.
Some nursing interventions we're going to do is to ensure proper fluid resuscitation. So, you want to make sure that you have IV fluids like isotonic fluids to help flush out any sort of muscle proteins and electrolytes. You can also prevent kidney damage by hydrating patients. You want to insert a Foley catheter and record strictly I & O for these patients. So, this is going to enable a nurse to closely monitor a patient's urine output. Also make sure you know how much the patient's taking in as well. Be mindful though, when you do insert a Foley, that there is a higher risk of infection. So, make sure you're following your hospital protocol with foley care. We're going to monitor labs. So, it's going to dictate the treatment regimen for patients with rhabdomyolysis. So, you're going to be checking CK, serum, urine, pH, bicarbonate, electrolytes, and of course, kidney function for these patients. Another thing to consider is that any electrolyte imbalances that you may have such as potassium, calcium, phosphate, or magnesium are particularly important. You want to make sure that you're replacing them per the protocol at your hospital. You want to monitor compartment syndrome. So, if there is significant muscle injury compartment syndrome is a big risk. So, muscle injury is very typical and can cause decreased perfusion. For the patient discharge planning, you want to make sure that we're educating the patient on diet activity level and any sort of prevention that enables this to not happen. This is very common in athletes, especially with CrossFit - in today's day and age of people that are working out really hard. So, you want to talk about just having decreased activity, diet, preventing the future if metabolic cause, activity caution with intense workouts and making sure that they are hydrating properly. And we also want to do medication history. So, we want to see if they're on any statins, diuretics, aspirin overdose, recreational drugs, such as cocaine or amphetamines and narcotic use that is also a risk for rhabdo.
So, some key points we're going to be considering here. So patho, when skeletal muscles are destroyed their intracellular contents, such as myoglobin, leak into the bloodstream. It is caused by high intensity workouts, such as CrossFit, some trauma, seizures, metabolic issues, temp regulating issues, and many medications. So, make sure you're telling your physician any sort of medications you're on as that can cause rhabdo. Some subjective and objective. What you're going to see patients will complain of are muscle pain, cramps, aches, are very, very common. General weakness, nausea, tender muscles, dark urine, are very common. So, it'll be tea-colored urine, vomiting, fever, edema, skin changes may even look necrotic, intense muscles, fluids, I & O, labs, and sure. Proper IV fluid resuscitation, insert foley for proper I&O, monitor labs, such as your electrolytes, urine, serum and kidney functions, and replace electrolytes per orders, compartment syndrome monitoring, and discharge education. Make sure you're monitoring for signs of compartment syndrome as that can be decreased perfusion, educate the patient upon discharge to prevent rhabdo to make sure they're hydrated. Make sure that they're cutting down on some of the physical activity. If they're doing CrossFit, for instance, and making sure you're getting a full medication history. You guys are doing awesome. Thank you so much.
We love you guys. Go out and be the best version of yourself and as always happy nursing.
So, if we're going to go over the care plan, we're going to be going over some of the subjective data, things that you're going to see with the patient and objective data. So, some subjective data, one of the major ones with rhabdo is going to be some cramp in the legs and some generalized weakness. Also, a very classic sign is going to be very dark colored urine, and I'm talking Cola color or tea color is what you'll see with this patient. That's because of the breakdown of those proteins. You'll also see some nausea, tender muscles, vomiting, fever, edema, and possible skin changes, which may even look necrotic on some patients.
Some nursing interventions we're going to do is to ensure proper fluid resuscitation. So, you want to make sure that you have IV fluids like isotonic fluids to help flush out any sort of muscle proteins and electrolytes. You can also prevent kidney damage by hydrating patients. You want to insert a Foley catheter and record strictly I & O for these patients. So, this is going to enable a nurse to closely monitor a patient's urine output. Also make sure you know how much the patient's taking in as well. Be mindful though, when you do insert a Foley, that there is a higher risk of infection. So, make sure you're following your hospital protocol with foley care. We're going to monitor labs. So, it's going to dictate the treatment regimen for patients with rhabdomyolysis. So, you're going to be checking CK, serum, urine, pH, bicarbonate, electrolytes, and of course, kidney function for these patients. Another thing to consider is that any electrolyte imbalances that you may have such as potassium, calcium, phosphate, or magnesium are particularly important. You want to make sure that you're replacing them per the protocol at your hospital. You want to monitor compartment syndrome. So, if there is significant muscle injury compartment syndrome is a big risk. So, muscle injury is very typical and can cause decreased perfusion. For the patient discharge planning, you want to make sure that we're educating the patient on diet activity level and any sort of prevention that enables this to not happen. This is very common in athletes, especially with CrossFit - in today's day and age of people that are working out really hard. So, you want to talk about just having decreased activity, diet, preventing the future if metabolic cause, activity caution with intense workouts and making sure that they are hydrating properly. And we also want to do medication history. So, we want to see if they're on any statins, diuretics, aspirin overdose, recreational drugs, such as cocaine or amphetamines and narcotic use that is also a risk for rhabdo.
So, some key points we're going to be considering here. So patho, when skeletal muscles are destroyed their intracellular contents, such as myoglobin, leak into the bloodstream. It is caused by high intensity workouts, such as CrossFit, some trauma, seizures, metabolic issues, temp regulating issues, and many medications. So, make sure you're telling your physician any sort of medications you're on as that can cause rhabdo. Some subjective and objective. What you're going to see patients will complain of are muscle pain, cramps, aches, are very, very common. General weakness, nausea, tender muscles, dark urine, are very common. So, it'll be tea-colored urine, vomiting, fever, edema, skin changes may even look necrotic, intense muscles, fluids, I & O, labs, and sure. Proper IV fluid resuscitation, insert foley for proper I&O, monitor labs, such as your electrolytes, urine, serum and kidney functions, and replace electrolytes per orders, compartment syndrome monitoring, and discharge education. Make sure you're monitoring for signs of compartment syndrome as that can be decreased perfusion, educate the patient upon discharge to prevent rhabdo to make sure they're hydrated. Make sure that they're cutting down on some of the physical activity. If they're doing CrossFit, for instance, and making sure you're getting a full medication history. You guys are doing awesome. Thank you so much.
We love you guys. Go out and be the best version of yourself and as always happy nursing.
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