Acute Care Case Study

Questions: 1.What is rhabdomyolosis? 2.How is Rhabdomyolosis treated?3.What are the complications associated with the condition?4.Why did they do an ECG in the emergency department? What was the rhythm?5.Explain the reason for Tims Pyrexia?6.Explain the results of urinalysis.7.Explain the reason of the pathology tests provided. Answers: 1. Any muscle injury that may be both direct and indirect may often lead to a serious condition where death of muscle fibres takes place. The contents are released into the bloodstream and often might result on kidney dysfunction and failure (Ruiz et al. 2013). This is mainly because the kidney fails to remove any sort of waste as well as concentrated urine and therefore may present concentrated brown coloured urine. In Tims case one can say that out of the several diseases that cause this syndrome, excessive rise of body temperature resulted in a heat stroke that have resulted in muscle injury during the trialothon that was the cause of the disease. Moreover, very less sleep in the previous night was an additional reason for it. 2. A patient suffering from rhabdomyolosis should be monitored with adequate hydration and his urine output should be recorded. Fluid should be resuscitated so that the body fluid remains optimum (Mausavi et al.2015). Organ which gets affected should be immediately treated. Electrolyte balance should be maintained and ECG should be done to monitor the level of potassium and other electrolyte balances. Once the fluid content, electrolyte balances and failed organs becomes stabilised and the person feels well, he can be discharged from the hospital. In case of Tim ECG reported showed imbalances in the various salts present in his body that confirmed that he was suffering from rhabdomyolosis. 3. Rhabdomyolosis which is defined as skeletal muscle injury. Myocyte calcium homeostasis is mainly affected by the excessive release of the myoglobin (A Myocyte compound) can precipitate in the glomerular filtrate because the level exceeds the level of protein binding (Chen, Bai and Chang 2014). Renal obstruction thereby causes kidney failure. Apart from this it also results in hyperuricemia, hypoalbuminemia, electrolyte imbalances and disseminated intravascular coagulation and also compartment syndrome. 4. Rhabdomyolosis mainly occurs due to the increased levels of potassium. ECG known as electrocardiogram is usually helpful in checking the elevated levels of potassium because it affects the conducting system of the heart (Tucker 2015). This can be understood by the images that can be produced by ECG showing the T WAVE or QRS complex broadening (Parekh et al. 2013). Increased extracellular potassium is expected to affect the myocardial excitability by affecting the pacemakers and the conducting tissue system (Na and Chunxia 2013). In serious cases of hyperkalemia, generation of impulse is suppressed and reduced conduction by the SA node and AV node respectively which leads to bradycardia and even to cardiac arrest in extreme cases. The images provided from Tims ECG shows elevated T waves that can determine his serum potassium that may represent a level of about K+ as 7.0. If this serum level reaches to K+ of about 9 it would lead to cardiac arrest. Tim was therefore administered into the hospital so that he was protected from cardiac arrest. 5. Pyrexia otherwise known as fever is a natural body mechanism that marks the presence of any injury or disease in the body. The hypothalamus consists of a particular gland that is responsible for the cooling or heating of the body. The biochemical molecules called pyrogens are released when any harmful microorganisms are present in the body or may be from injured body tissues directly into blood system (Yunhui and Jings 2013). This is the bodys way of response to create an environment to clear the microorganisms by raising the temperatures. In case of Tim one can see how his skeletal muscles got injured leading to rhabdomyolosis which was the main reason for Tims pyrexia. 6.Urinalysis is a very simple way of confirming the occurrence of rhabdomyolosis (Desjardins and Strange 2013). In case of Tims urine , presence of the brown sediment giving a dark cola like colour signifies the presence of heme content because it makes the urine dark brown in colour when present. Presence of pH less than 5.5 usually demarcates the chance of this syndrome; Tims urine has a ph of 4 which signifies that immediate fluid resuscitation is important. It is already known that urine should be analysed as positive for the presence of blood but negative for RED blood corpuscles. During this syndrome, myoglobin protein breaks down into heme which can be identified by using a dipstix that is sensitive for heme. As a result presence of blood may confirm the disease which is mainly due to myoglobin as well. A value of SG 1025 may indicate dehydration problems that require immediate rehydration procedures. 7. Increased level of potassium is a marker for the presence of rhabdomyolosis. This increased level is harmful for the cardiac system as it harms the action potential generation and leads to cardiac arrhythmias (Manspeaker, Henderson and Riddle 2014). Low level of calcium as seen in Tims blood also suggests that calcium influx has taken place in the muscle cells mainly due to ATP depletion. Uncontrolled entry of calcium takes place which causes continuous and persistent contraction for which the muscle cells get injured thereby damaging and breaking down the intracellular proteins (Packard, Price and Hanson 2014). So this also says the reason why Tims blood has excessive protein than normal. Moreover much creatinine level and urea demarcates the failure of the kidney which thereby give a sign of the kidney malfunctioning. CreatininKinase MB Isoenzyme tests usually become very high than the normal level during skeletal muscle injury which is another proof of the occurrence of Rhabdom yolosis (Biswas et al 2013). intake time amount oral tube nature 1500 30 mls oral water 1515 1000mls Hartmans Salt balance 1515 1000 mls Hartmans Salt balance 1515 1000 mls 4% Dextrose 1/5 N/Saline Salt balance 1515 1000 mls N/Sline with 1000 mmol NaHCo3 Salt balance 1600 30 mls oral water 1700 30 mls oral water Output time Urine faeces vomit comment 1530 320 mls Dark cola colour 1630 200 mls Dark cola colour 1730 145 mls Dark cola colour Potential problem problem intervention Urine quality and quantity have to be checked at regular hours. Continuous urinalysis to be donr for Tim Vital signs have to be continuously recorded Regular monitoring of vital signs in every hours to check BP, HR, BT and RR which was more or less fine for TIM Fluid balance have to be continuously monitored This is to be done because salt imbalances may become lethal because Tim had weak salt balance known from pathology tests. Acute problems: problem Intervention: Kidney failure for Tim could not produce normal urine Dialysis ECG showed tendency of bradycardia and cardiac arrest. Potassium levels to be kept in check Muscle injury in Tims limbs Gradual level in rise of blood Calcium and decreased level of intracellular Ca has to be maintained. Progress notes:- The vital signs that has been observed in the period from 1500 to 1700 showed irregular heart rate but was within the nondanger zone. Similarly the Body temperature was slightly above the normal body temperature of 38.5? C that resulted in a slightly feverish feeling. However the blood pressure was far below the normal level and it can be said that Tim suffered from hypotension. The respiratory rate was also found to be normal. The skin gradually became warm from cold and dry feeling which was appositive side of his revival. The urine output also reduced in course of time which was also a positive sign. So the monitoring of the vital signs helped us to understand the response of patient Tim. Blood pressure and body temperature of the patient was found to be gradually becoming normal but the heart rate and the respiratory rate was found to show abnormality. The heart rate was found to go above the normal value of 80 thereby proving that he has cardiac anomalies and the condition was worsening. The respiratory rate was found to be going above the normal value of 20 to 24 showing problems in respiratory passage. Gradual development of pain showed that further degeneration of the muscles were taking place leading to increased generation of potassium that if not controlled might lead to cardiac arrest. During following the ABC intervention in the treatment of rhabdyolosis, first the nurse has to keep the patient conscious and monitor whether he can recognise surrounding (Haiyan et al. 2014). Their alertness is to be examined. Patients AIRWAYS have to be kept cleared by nasal canaliculi. Airway manoeuvres, bag and valve mask and other processes. Then one has to check the breathing of the patient in order to see whether he is using accessory muscles or breathing normally. As Tim had abnormal RR, then the intervention one can provide may be using bag valve mask so that he can maintain optimum tidal volume. Oxygen may be provided if necessary. Intubation and ventilation can be used depending upon the further deterioration of the patient. Circulatory system analysis has to be done in order to understand the rise of heart rate and take interventions accordingly to make their heart rate stable. References: Biswas, S., Rao, R.S., Duckworth, A., Kothuru, R., Flores, L. and Abrol, S., 2013. Bilateral Atraumatic Compartment Syndrome of the Legs Leading to Rhabdomyolysis and Acute Renal Failure Following Prolonged Kneeling in a Heroin Addict. A Case Report and Review of Relevant Literature.Panamerican Journal of Trauma, Critical Care and Emergency Surgery,2(3), p.139. Chen, L.C., Bai, Y.M. and Chang, M.H., 2014. Polydipsia, hyponatremia and rhabdomyolysis in schizophrenia: A case report.World journal of psychiatry,4(4), p.150. Desjardins, M. and Strange, B., 2013. Pre-hospital treatment of traumatic rhabdomyolysis: Mathew Desjardins and Barnaby Strange discuss the aetiology and management of traumatic pathological breakdown of skeletal muscle tissue.Emergency Nurse,21(8), pp.28-33. Haiyan, S., Shiyang, Z., Yang, L. and Shaojuan, C., 2014. Effect of continuous hemofiltration on acute renal injury induced by rhabdomyolysis and relevant nursing strategies.Modern Clinical Nursing,1, p.011. Manspeaker, S., Henderson, K. and Riddle, D., 2014. Treatment of exertional rhabdomyolysis among athletes: a systematic review protocol.JBI Database of Systematic Reviews and Implementation Reports,12(3), pp.112-120. Mousavi, S.R., Vahabzadeh, M., Mahdizadeh, A., Vafaee, M., Sadeghi, M., Afshari, R. and Balali-Mood, M., 2015. Rhabdomyolysis in 114 patients with acute poisonings.Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences,20(3), p.239. Na, L. and Chun-xia, O., 2013. Nursing care of 1 case of rhabdomyolysis caused multiple organ failure. Packard, K., Price, P. and Hanson, A., 2014. Antipsychotic use and risk of rhabdomyolysis.Journal of pharmacy practice, p.0897190013516509. Parekh, R., Care, D.A. and Tainter, C.R., 2012. 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