- Acute Pain Related to Inflammatory process as evidenced by Muscle tenderness and Myalgia even at rest
- Deficient Fluid Volume Related to Skeletal muscle injury and electrolyte imbalances as evidenced by Increased urine concentration and Decreased urine output
- Impaired Physical Mobility Related to Muscle weakness and Immobility as evidenced by Altered gait and Spastic movement
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain Related to Inflammatory process as evidenced by Muscle tenderness and Myalgia even at rest | 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. 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. | The patient verbalized pain relief as evidenced by increasing activity levels The patient reported pain level of 2 or less by discharge |
| Subjective data: Verbalizes unable to drink fluids Objective data: -Electrolyte imbalances -Decreased blood pressure -Increased urine concentration -Decreased urine output -Altered BUN/creatinine | Deficient Fluid Volume Related to Skeletal muscle injury and electrolyte imbalances as evidenced by Increased urine concentration and Decreased urine output | The patient will maintain urine output within normal limits The patient will exhibit BUN and creatinine levels within normal limits | 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. | The patient-maintained urine output within normal limits The patient exhibited BUN and creatinine levels within normal limits |
| Subjective data: Expression of pain and discomfort with movement Refusal to move Objective data: -Limited range of motion -Uncoordinated movements -Postural instability -Gait disturbances -Reliance on assistive devices -Contractures -Decreased muscle strength | Impaired Physical Mobility Related to Muscle weakness and Immobility as evidenced by Altered gait and Spastic movement | The patient will demonstrate increased strength and ability to move The patient will participate in physical therapy twice per week | 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. | The patient demonstrated increased strength and ability to move The patient participated in physical therapy twice per week |