Nursing Care Plan for Rhabdomyolysis

1. Nursing Diagnosis: Risk for Acute Kidney Injury (AKI) related to myoglobinuria secondary to rhabdomyolysis

Goal: Prevent or minimize kidney damage and maintain adequate renal function.

Interventions:

Monitor urine output closely: Measure and document urine output hourly to assess for oliguria (<400 mL/day) or anuria, which are signs of worsening renal function.
Administer intravenous fluids (IVF): Provide aggressive fluid resuscitation (e.g., isotonic saline at 200–500 mL/hr initially) to promote diuresis and prevent myoglobin deposition in the kidneys.
- Titrate IVF based on hemodynamic status, urine output, and laboratory values (e.g., serum creatinine, BUN).
Monitor labs: Check serum creatinine, blood urea nitrogen (BUN), electrolytes, and creatine kinase (CK) levels frequently to evaluate kidney function and muscle breakdown severity.
Alkalinize urine: Administer sodium bicarbonate as prescribed to maintain urinary pH >6.5, which reduces myoglobin precipitation in the renal tubules.
Assess for signs of AKI: Monitor for symptoms such as decreased urine output, elevated creatinine/BUN, edema, or hypertension.

Evaluation:

Patient maintains adequate urine output (>0.5 mL/kg/hr).
Serum creatinine and BUN levels stabilize or decrease.
No clinical signs of AKI develop.

2. Nursing Diagnosis: Imbalanced Electrolytes related to muscle breakdown and renal dysfunction

Goal: Restore and maintain normal electrolyte balance.

Interventions:

Monitor serum electrolytes: Frequently check potassium, calcium, phosphorus, and magnesium levels.
- Hyperkalemia: Watch for ECG changes (e.g., peaked T waves, widened QRS) and administer treatments like insulin + glucose, calcium gluconate, or sodium polystyrene sulfonate as ordered.
- Hypocalcemia: Assess for symptoms such as tetany, Chvostek’s sign, or Trousseau’s sign. Administer calcium supplements if needed.
- Hyperphosphatemia: Restrict dietary phosphate intake and administer phosphate binders as prescribed.
Educate about diet: Provide guidance on low-potassium or low-phosphate diets, depending on lab results.
Administer medications: Give prescribed medications to correct electrolyte imbalances (e.g., calcium gluconate for hypocalcemia).

Evaluation:

Serum electrolyte levels normalize.
Patient remains free of symptoms of electrolyte imbalance (e.g., arrhythmias, muscle cramps, seizures).

3. Nursing Diagnosis: Risk for Fluid Volume Excess related to aggressive fluid therapy

Goal: Maintain fluid balance and prevent complications of fluid overload.

Intervants:

Monitor fluid status: Assess for signs of fluid overload (e.g., crackles in lungs, jugular venous distension, peripheral edema, weight gain).
Measure daily weights: Weigh the patient daily at the same time using the same scale to detect fluid retention.
Titrate IV fluids: Adjust IVF rate based on clinical status, urine output, and laboratory findings to avoid overhydration.
Monitor vital signs: Check for hypertension, tachycardia, or dyspnea, which may indicate fluid overload.
Administer diuretics: If prescribed, give loop diuretics (e.g., furosemide) to promote diuresis while monitoring electrolytes.

Evaluation:

Patient maintains stable weight and no signs of fluid overload.
Vital signs remain within normal limits.

4. Nursing Diagnosis: Acute Pain related to muscle injury and inflammation

Goal: Relieve pain and discomfort associated with muscle breakdown.

Interventions:

Assess pain level: Use a pain scale (e.g., 0–10) to evaluate the intensity, location, and quality of pain.
Provide comfort measures: Encourage rest, apply warm or cold compresses to affected muscles, and position the patient comfortably.
Administer analgesics: Give prescribed pain medications (e.g., acetaminophen, NSAIDs) as needed, avoiding nephrotoxic drugs like NSAIDs if renal function is compromised.
Monitor for complications: Watch for worsening muscle pain, swelling, or weakness, which may indicate ongoing muscle breakdown.

Evaluation:

Patient reports reduced pain levels.
Verbalizes comfort and ability to rest.

5. Nursing Diagnosis: Knowledge Deficit related to lack of understanding of rhabdomyolysis and its management

Goal: Patient and family demonstrate understanding of the condition and treatment plan.

Interventions:

Explain the condition: Teach the patient and family about rhabdomyolysis, including its causes (e.g., trauma, crush injuries, prolonged immobilization, medications, toxins), symptoms, and potential complications.
Discuss treatment plan: Explain the importance of hydration, monitoring urine output, and preventing further muscle injury.
Highlight preventive measures: Educate about avoiding risk factors (e.g., excessive exercise, dehydration, certain medications) and recognizing early warning signs (e.g., dark urine, muscle pain).
Encourage follow-up care: Stress the importance of regular follow-up appointments and lab tests to monitor recovery.

Evaluation:

Patient and family verbalize understanding of rhabdomyolysis and its management.
Demonstrates adherence to the treatment plan and preventive measures.

Summary

This nursing care plan addresses the key aspects of managing rhabdomyolysis, including prevention of kidney injury, correction of electrolyte imbalances, maintenance of fluid balance, pain management, and patient education. Early recognition and intervention are critical to minimizing complications and promoting recovery.

Nursing Care Plan for Rhabdomyolysis