Rhabdomyolysis is characterized by the breakdown of muscle fibers that releases muscle components into the blood. This condition can result from trauma, overexertion, toxic substances, ischemia, infections, prolonged bed rest, and other underlying health conditions.
Myoglobin, creatine kinase, electrolytes, and other substances are released into the blood when the muscles become damaged. In excess, these substances can damage the kidneys, leading to kidney failure and death if untreated.
Though this condition can occur in anyone, it is more commonly found in endurance athletes, military personnel, firefighters, and older adults. Various factors contribute to muscle damage and the development of rhabdomyolysis. These causes include:
- High-intensity exercise
- Severe dehydration
- Compression syndrome
- Substance abuse
- Metabolic disorders
- Long periods of inactivity
Signs and symptoms of rhabdomyolysis can range from mild to severe and they develop one to three days after muscle trauma or injury. The classic signs of this condition include:
- Muscle swelling
- Tender, weak, and sore muscles
- Dark, tea-colored urine
Typical tests that healthcare providers use to confirm the diagnosis of this condition include a detailed physical and medical history including recent physical activity, prescription medications, the use of illegal substances, and any recent trauma or injuries. Urine tests measure myoglobin in the urine and blood tests measure creatine kinase levels.
The Nursing Process
The primary goal for treating rhabdomyolysis is fluid resuscitation to restore intravascular volume, dilute myoglobin and other toxins, and restore kidney function. Nurses play a key role in administering treatment interventions and monitoring for complications such as kidney failure.
Nursing Care Plans Related to Rhabdomyolysis
Impaired Physical Mobility
Impaired physical mobility can be a cause or a complication of rhabdomyolysis.
Nursing Diagnosis: Impaired Physical Mobility
- Myalgia or muscle pain
- Muscle weakness
- Decreased activity tolerance
- Decreased muscle control
- Decreased muscle strength
- Prescribed bed rest
As evidenced by:
- Altered gait
- Decreased range of motion
- Difficulty turning
- Expresses discomfort
- Postural instability
- Slowed movement
- Spastic movement
- The patient will demonstrate increased strength and ability to move
- The patient will participate in physical therapy twice per week
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.
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.
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
- 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
- The patient will maintain urine output within normal limits
- The patient will exhibit BUN and creatinine levels within normal limits
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.
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.
Typical signs and symptoms of rhabdomyolysis include muscle swelling, pain, stiffness, and weakness.
Nursing Diagnosis: Acute Pain
- Inflammatory process
- Disease process
As evidenced by:
- Muscle tenderness
- Myalgia even at rest
- Hesitancy with movement
- Guarding behavior
- Positioning to ease pain
- The patient will verbalize pain relief as evidenced by increasing activity levels
- The patient will report a pain level of 2 or less by discharge
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.
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.
References and Sources
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Rhabdomyolysis. Annie Stuart. Reviewed by Jennifer Robinson, MD. WebMD. Reviewed: March 17, 2021. From: https://www.webmd.com/a-to-z-guides/rhabdomyolysis-symptoms-causes-treatments
- Rhabdomyolysis. CDC Centers for Disease Control and Prevention. Reviewed: April 22, 2019. From: https://www.cdc.gov/niosh/topics/rhabdo/default.html
- Rhabdomyolysis. MedlinePlus Trusted Healthcare for You. Updated by: Walead Latif, MD, Nephrologist and Clinical Associate Professor, Rutgers Medical School, Newark, NJ. Reviewed: July 27, 2021. From: https://medlineplus.gov/ency/article/000473.htm
- Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Ochsner J. 2015 Spring;15(1):58-69. PMID: 25829882; PMCID: PMC4365849. From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365849/