Rhabdomyolysis is characterized by the breakdown of muscle that releases excessive myoglobin, creatine kinase, electrolytes, and other substances into the bloodstream. Toxic levels of these substances can lead to acute kidney injury and even kidney failure in severe cases. Other serious complications include compartment syndrome and disseminated intravascular coagulation (DIC).
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Fluid Volume
- Impaired Physical Mobility
- Impaired Urinary Elimination
- Impaired Tissue Integrity
Overview
Rhabdomyolysis can result from a broad array of causes. Traumatic or physical causes include crush or fracture injuries from motor vehicle accidents or natural disasters like earthquakes, electrical injuries, abuse, prolonged immobility, or strenuous exercise.
Nontraumatic or nonphysical causes include medications/supplements, drug use, ischemia, infections, and other underlying metabolic or genetic conditions.
Patients commonly report muscle pain, tenderness, swelling, stiffness, weakness, and dark-colored urine, though these manifestations are not always present.
This condition can occur at any age and patient population, though adults account for most cases. Pediatric rhabdomyolysis is often related to infection.
Nursing Process
Nurses play a key role in identifying potential causes of rhabdomyolysis, administering immediate interventions, monitoring outcomes and treatment effectiveness, and intervening to prevent complications.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to rhabdomyolysis.
Review of Health History
1. Ask the patient about their general symptoms.
Signs and symptoms of rhabdomyolysis can range from mild to severe and typically develop one to three days after muscle trauma or injury. The classic triad of symptoms is muscle pain, weakness, and dark, tea-colored urine, though these are only observed in about half of patients. The patient may report nonspecific symptoms like fever, nausea, and vomiting.
2. Determine a possible inciting event.
Various factors contribute to muscle damage and the development of rhabdomyolysis. The nurse can evaluate for:
- High-intensity exercise (especially in untrained people)
- Heat exhaustion
- Electrical injuries
- Blunt trauma or crush injuries
- Serious burns
- Near-drowning
- Prolonged immobilization (after excessive alcohol or drug use, a surgical procedure, a coma, or a fall in an older adult)
3. Review the patient’s medical history.
Nontraumatic or nonphysical causes of rhabdomyolysis can occur from ischemia, infections, electrolyte alterations, or metabolic conditions, such as:
- Infections (viral myositis, COVID-19, sepsis)
- Severe dehydration
- Hyperosmolar hyperglycemic state or diabetic ketoacidosis with coma
- Genetic conditions like McArdle disease, muscular dystrophy, or sickle cell anemia
- Toxins from an insect or snake bite or carbon monoxide poisoning
4. Track the patient’s medications and substance abuse.
Review the use and abuse of medications and substances. The following substances can contribute to rhabdomyolysis:
- Medications
- Antipsychotics
- Antidepressants
- Antihistamines
- Salicylates
- Anesthetics and paralytic drugs
- Statins (the most common medication related to rhabdomyolysis)
- Substances
- Heroin
- Amphetamines
- Cocaine
- Alcohol
- Opiates
Note: Rhabdomyolysis can occur from using illegal substances as the patient may lay in one position for an extended time while intoxicated, causing pressure necrosis to the muscles.
5. Consider the patient’s occupation or lifestyle.
Adults with physically intense jobs in hot environments, such as firefighters, construction workers, or certain military personnel, are at risk for rhabdomyolysis. Endurance athletes like marathon runners may also place themselves at risk through overexertion.
Physical Assessment
1. Assess overall complaints.
The classic triad of symptoms may only occur in 50% of patients. The patient may report some degree of muscle involvement or symptoms of fatigue, fever, nausea, and vomiting.
2. Perform a musculoskeletal assessment.
If orthopedic injuries following trauma are suspected, look for any skeletal deformities in the long bones or crush injuries. Inspect and palpate for the following:
- Soft tissue swelling
- Decreased muscle strength
- Muscle tenderness or stiffness
- Skin abnormalities indicative of pressure necrosis
3. Rule out other conditions.
The lower back and calves are the most frequently affected muscle groups of adults with rhabdomyolysis. Angina or deep vein thrombosis are two conditions that mimic rhabdomyolysis and must be ruled out.
4. Monitor the patient’s temperature.
Rhabdomyolysis may result from electrical injuries, hypothermia, and hyperthermia. Monitor the patient’s body temperature routinely.
5. Monitor for complications.
Compartment syndrome is a serious complication of rhabdomyolysis. The nurse should frequently evaluate the patient’s peripheral pulses and sensations and palpate for tense muscles that indicate compartment syndrome.
Diagnostic Procedures
1. Obtain blood samples for laboratory tests.
The following laboratory tests are expected:
- Complete blood count
- Serum electrolytes
- Kidney function tests
- Liver function tests
- Coagulation profile
- Serum aldolase
- Lactate dehydrogenase
2. Review enzyme levels.
Creatine kinase (CK) is the most sensitive indicator of muscle damage. CK levels rise 12 hours after injury, peak in 24-36 hours, and then decline within 3-5 days. CK levels are typically drawn every 6-12 hours to determine a peak level. In rhabdomyolysis, levels are often five times the reference range but may also be much higher. Myoglobin has a short half-life and is removed from plasma within 6 hours, making it a less reliable indicator.
3. Obtain a urine sample.
Urine may be obviously discolored (dark, red, brown), though microscopic analysis will differentiate myoglobinuria from blood. Note that a normal result does not rule out rhabdomyolysis.
4. Prepare the patient for imaging studies.
Imaging studies are not necessary to diagnose rhabdomyolysis, but the following tests may be ordered to assess for fractures, head injuries, or complications like compartment syndrome:
- X-ray
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
5. Anticipate a muscle biopsy for recurrent cases.
Patients with rhabdomyolysis have necrotic muscle fibers visible on histology. A muscle biopsy can identify possible skeletal muscle disorders for patients whose cause is inconclusive or when rhabdomyolysis is recurring.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from rhabdomyolysis.
1. Prioritize fluid resuscitation.
Large volumes of IV fluids are required to improve organ perfusion and promote diuresis with the goal of preventing AKI.
2. Promptly obtain an ECG.
An ECG should be performed initially in the assessment of rhabdomyolysis, as the electrolyte alterations that occur can cause cardiac dysrhythmias. Continuous monitoring may be advised to monitor for complications.
3. Monitor intake and output.
Close intake and output monitoring is crucial for the patient receiving large-volume resuscitation. Insert a urinary catheter and document intake and output as required.
4. Treat complications that arise.
DIC disrupts the body’s clotting factors and is treated with fresh frozen plasma, cryoprecipitate, and platelet transfusions. Compartment syndrome will require an emergency fasciotomy.
5. Manage underlying causes.
Administer antibiotics for sepsis, steroids for inflammatory myopathies, dantrolene sodium for malignant hyperthermia, and prepare for orthopedic surgery for fracture repair.
6. Utilize IV medications.
Urine alkalization is recommended to prevent myoglobin precipitation that can obstruct the renal tubules. IV sodium bicarbonate is added to IV fluids to reach a urine pH of 6.5 – 7.5. IV diuretics like mannitol or furosemide may also be considered if the urine output is inadequate. Frequently monitor electrolyte levels and acid-base balance and administer sodium bicarbonate, dextrose, insulin, or calcium chloride for hyperkalemia. Use calcium with caution, as hypercalcemia may occur later in the disease process.
7. Initiate dialysis for severe cases.
Patients with oliguria, persistent hyperkalemia, volume overload, or metabolic acidosis may require dialysis.
8. Refer the patient to physical therapy.
Severe cases of rhabdomyolysis may require physical therapy and rehabilitation to regain muscle mass.
9. Educate on prevention.
Depending on the cause, education may be necessary to prevent a future occurrence of rhabdomyolysis. Some patients should limit strenuous activities, especially in the heat, and rehydrate frequently. If alcohol or illicit drugs are an inciting cause, refer to substance abuse counseling. Patients with genetic conditions or inflammatory myopathies may benefit from dietary changes, medication, and follow-up with a rheumatologist.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for rhabdomyolysis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for rhabdomyolysis.
Acute Pain
Typical signs and symptoms of rhabdomyolysis include muscle swelling, pain, stiffness, and weakness.
Nursing Diagnosis: Acute Pain
Related to:
- Inflammatory process
- Disease process
As evidenced by:
- Muscle tenderness
- Myalgia even at rest
- Hesitancy with movement
- Guarding behavior
- Positioning to ease pain
Expected outcomes:
- Patient will verbalize pain relief as evidenced by increasing activity levels.
- Patient will report a pain level of 2 or less by discharge.
Assessment:
1. Assess pain characteristics.
Pain assessment can help diagnose rhabdomyolysis. Myalgia at rest along with muscle weakness coupled with systemic features of fever, nausea, and tea-colored urine can differentiate from other causes.
2. Consider other chronic conditions.
When assessing and treating pain, consider other diagnoses the patient may have that contribute to pain unrelated to rhabdomyolysis such as fibromyalgia, surgical pain, arthritis, neuropathy, and more. Each type of pain may require different management.
Interventions:
1. Administer pain medications as ordered.
Pain medications like ibuprofen and other NSAIDs should be avoided as these medications can worsen kidney function in patients with rhabdomyolysis. Acetaminophen may be given to help relieve pain without compromising kidney function.
2. Rest muscles.
Resting the injured muscles is necessary to allow the fibers to recover. When returning to exercise, do so slowly and rest as needed.
3. Treat muscle pain with nonpharmacologic interventions.
Treating muscle pain in rhabdomyolysis with nonpharmacologic interventions like massage and warm compresses can help relieve discomfort while regaining strength.
4. Ensure adequate circulation.
Elevating limbs with proper support can ensure circulation which eases feelings of weakness, tingling, and pain. The nurse should also assess peripheral pulses, and skin color and warmth to ensure perfusion and circulation.
Deficient Fluid Volume
Hypovolemia and serum electrolyte imbalances are common in patients diagnosed with rhabdomyolysis. When the muscles are damaged, they release proteins and electrolytes into the body. Hypovolemia, along with the accumulation of myoglobin, increases the risk of kidney injury.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Disease process
- Skeletal muscle injury
- Electrolyte imbalances
- Acute kidney injury
As evidenced by:
- Altered mental status
- Tea-colored urine
- Altered skin turgor
- Electrolyte imbalances
- Decreased blood pressure
- Increased body temperature
- Increased heart rate
- Increased urine concentration
- Decreased urine output
- Altered BUN/creatinine
Expected outcomes:
- Patient will maintain urine output within normal limits.
- Patient will exhibit BUN and creatinine levels within normal limits.
Assessment:
1. Assess and monitor the patient’s fluid status.
Accurately measuring the patient’s intake and output can help determine appropriate interventions, monitor any possible complications, and monitor the effectiveness of the current treatment.
2. Assess electrolyte values.
Rhabdomyolysis is associated with prominent fluid and electrolyte imbalances like hyperphosphatemia, hypocalcemia, hyperkalemia, hypercalcemia, hyperuricemia, and hypoalbuminemia.
3. Monitor kidney function.
BUN and creatinine results will help monitor the progression of acute kidney injury. Urine output should also be assessed for amount and color per facility policy.
Interventions:
1. Provide fluid replacement intravenously and orally.
Fluid therapy in rhabdomyolysis helps increase urine output and prevent kidney damage. IV fluids also help flush out excess muscle proteins and electrolytes from damaged muscles.
2. Replace electrolytes.
Electrolytes may need replacement. Hyperkalemia may require potassium binders or D50 with IV sodium bicarbonate. Symptomatic hypocalcemia may require IV calcium gluconate.
3. Instruct on adequate fluid intake with exercise.
The combination of extreme exercise or activity combined with a lack of fluids can create an environment for rhabdomyolysis. Athletes, service members, and firefighters may require extra fluid intake.
4. Prepare the patient for dialysis.
Dialysis may be indicated in severe cases to help the kidneys filter waste products while recovering.
Impaired Physical Mobility
Impaired physical mobility can be a cause or a complication of rhabdomyolysis.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Myalgia or muscle pain
- Muscle weakness
- Decreased activity tolerance
- Decreased muscle control
- Decreased muscle strength
- Immobility
- Prescribed bed rest
- Falls
As evidenced by:
- Altered gait
- Decreased range of motion
- Difficulty turning
- Expresses discomfort
- Postural instability
- Slowed movement
- Spastic movement
Expected outcomes:
- Patient will demonstrate increased strength and ability to move.
- Patient will participate in physical therapy twice per week.
Assessment:
1. Assess the patient’s degree of immobility.
Rhabdomyolysis may cause muscle swelling, pain, and weakness. Immobility, such as prolonged bed rest or a fall, may also result in rhabdomyolysis and impaired physical mobility. It is important to determine the patient’s degree of immobility to ensure safety and to help plan appropriate rehabilitation interventions.
2. Assess the patient’s activity level.
Assessing the patient’s usual activity level can help determine who may be most at risk for rhabdomyolysis as well as guide their plan of care and recovery.
Interventions:
1. Assist the patient in self-care activities.
Assisting while encouraging self-performance in activities can help the patient gain a sense of control over their situation and promote independence while recovering.
2. Recommend starting an exercise program slowly.
Preventing another episode of rhabdomyolysis can be accomplished by beginning an exercise regimen slowly and not pushing beyond personal limits.
3. Implement safety precautions.
Some cases of rhabdomyolysis develop due to an older adult falling and not being able to get up. Their muscles deteriorate from not being able to move. Nurses can prevent this occurrence by educating on fall precautions or how to call for help when alone.
4. Refer the patient to a physical therapist.
A physical therapist can help further evaluate the patient’s immobility, physical training, and strength training, and formulate an appropriate mobility plan.
Impaired Urinary Elimination
Myoglobin and other substances released from muscle breakdown can damage renal cells, causing acute kidney injury and related urinary symptoms.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Disease process
- Excess of toxic substances in the bloodstream
- Acute kidney injury
As evidenced by:
- Dysuria
- Decreased urine output
- Anuria
- Dark-colored urine (red, brown, tea-colored)
Expected outcomes:
- Patient will demonstrate urine output and color within normal limits.
- Patient will remain free from symptoms of acute renal failure, such as decreased urine output, edema, and fatigue.
Assessment:
1. Assess the patient’s urine characteristics.
Excess myoglobin in the bloodstream overwhelms the kidney’s ability to filter waste products, causing dark urine that is usually red, brown, or tea-colored. As the condition worsens, urine output diminishes.
2. Assess and monitor laboratory values.
A microscopic urinalysis will detect the presence of myoglobin versus blood in the urine. Monitoring BUN, creatinine, and electrolyte levels is also important in evaluating the development of AKI.
Interventions:
1. Ensure hydration.
IV resuscitation is essential in the management of rhabdomyolysis and prevention of AKI. Fluids are necessary to manage dehydration/hypovolemia and maintain diuresis.
2. Monitor the patient’s intake and output.
Strict monitoring of the patient’s intake and output is important to determine fluid status and renal function. Insert a urinary catheter if necessary.
3. Assist and prepare the patient for dialysis.
If rhabdomyolysis has caused severe kidney damage, dialysis may be required to help the body get rid of toxins and waste products.
4. Administer medications as indicated.
Sodium bicarbonate can alkalinize the urine, and diuretics like furosemide promote urinary elimination if output is inadequate to prevent further deterioration of the patient’s kidney function.
Impaired Tissue Integrity
Rhabdomyolysis affects tissue integrity due to the breakdown of muscle fibers, causing muscle inflammation, weakness, pain, and necrosis in severe cases.
Nursing Diagnosis: Impaired Tissue Integrity
Related to:
- Disease process
- Electrolyte imbalances
- Ischemia
- Immobility
- Electrical injuries/burns
- Trauma/crush injuries/fractures
- Severe dehydration
- Strenuous exercise
As evidenced by:
- Muscle swelling
- Muscle tenderness
- Muscle stiffness
- Decreased muscle strength
- Muscle pain
- Skin discoloration
Expected outcomes:
- Patient will display improved muscle tissue integrity with decreased swelling, stiffness, and tenderness.
- Patient will demonstrate improved muscle strength and mobility.
Assessment:
1. Assess the extent of muscle weakness and other related symptoms.
Rhabdomyolysis is characterized by symptoms including muscle pain and aches (myalgias), muscle weakness, and dark-colored urine. The patient may present with swollen, stiff, and tender muscles. Recognizing the extent of muscle tissue injury and related symptoms can help determine the diagnosis and plan interventions.
2. Assess laboratory values to confirm rhabdomyolysis.
When muscle tissue is damaged, specific skeletal muscle enzymes are released into the bloodstream. Rhabdomyolysis can be confirmed with a blood test that shows an increased level of the muscle enzyme creatine kinase (CK) or creatine phosphokinase (CPK).
3. Assess possible causative factors of rhabdomyolysis.
Various factors can cause rhabdomyolysis, including traumatic accidents or injuries, high-intensity exercise, dehydration, prolonged immobility, infections, medications, and more. Understanding the causative factors of rhabdomyolysis can help plan appropriate interventions to correct the underlying etiology and prevent further complications.
Interventions:
1. Perform frequent neurovascular monitoring.
Compartment syndrome is a serious complication of rhabdomyolysis that can lead to muscle necrosis if not identified and treated. The nurse should closely monitor for changes in pulses, sensations, and skin color.
2. Correct electrolyte imbalances.
Electrolytes must be monitored closely as hyperkalemia, hyperphosphatemia, and hypocalcemia (followed by hypercalcemia later) occur in the disease process. These electrolytes are crucial to nerve and muscle function and may require correction.
3. Educate on exercising properly.
Overexertion from strenuous exercise is a significant cause of rhabdomyolysis. Educate the patient to begin any exercise program slowly, rest as needed, hydrate frequently, and listen to their body.
4. Refer the patient to physical therapy and rehabilitation.
Serious cases of rhabdomyolysis may require rehabilitation or physical therapy to restore muscle function and ensure a safe return to activity.
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