Fast-paced lifestyle

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Serum electrolytes must be monitored closely, and life-threatening abnormalities must be addressed promptly. Potassium levels generally peak 12 to 36 hours after injury (Dayer- Berenson 1994), and elevations are treated with standard hyperkalemic therapy (Russell 2000, Visweswaran & Guntupalli 1999). Unless patients are symptomatic, administration of exogenous calcium to correct hypocalcemia is not recommended.

With hydration, calcium remobilizes from the soft tissues and can cause hypercalcaemia (Vanholder et al 2000). All patients with rhabdomyolysis require continuous electrocardiographic monitoring for signs of hyperkalemia or cardiac irritability (Russell 2000, Haskins 1998). Compartment pressures may be measured in patients at risk for rhabdomyolysis due to extremity trauma (Slater & Mullins 1998).

Unfortunately Robert had a poor social network and had few visitors while he was in intensive care. Over the years he had lost contact with his family, and the majority of his close friends were connected with his fast-paced lifestyle. There were many challenges for Robert concerning his upcoming recovery. He faced the possibility of not regaining the use of his leg and consequently it was uncertain if he would be able to return to his profession as an Engineer. This placed his financial stability and lifestyle at risk. Physiotherapy was commenced in ITU by way of passive range of motion exercises and a leg splint to prevent foot-drop.

On the ward he was encouraged to keep his leg elevated and rested as requested by the surgeon to promote healing and later skin grafting. He was uncompliant with these orders and insisted on mobilising to go outside for cigarettes. The social workers attempted to assist with his financial and social problems. As he was still receiving sick pay from his employer he did not see his financial situation as an immediate threat. Robert was not interested in discussing his social situation or the possibility of work retraining.

While Robert was unable to care for himself his needs were attended by the nursing staff. Initially while he was intubated and sedated, mouth and eye care were performed every two hours. Pressure area care was attended second hourly and he was nursed side-to-side to promote lung drainage and maintain skin integrity. As Robert’s condition improved and he regained his independence he was encouraged to attend to his own hygiene needs. For his own safety, bedrails were kept in place. A nurse observed Robert at all times. He was continually orientated to his environment and all procedures explained prior to commencing. Environmental stressors such as excessive noise and light were kept to a minimum. These measures assisted to avoid unnecessary anxiety and consequently Robert was quite compliant with his personal care while in ITU.

Robert was offered drug rehabilitation services by the medical and nursing staff. Despite his long history of drug use, he failed to identify that he had a problem. During his hospital admission he did not show signs of drug withdrawal. The risk of infectious diseases such as HIV and hepatitis from Robert’s IV drug use was also discussed with him. He assured staff that he adhered to ‘safe’ needle practices; therefore, he did not see this as a problem. He did not recognise that by continuing his present lifestyle he was placing his life at risk. The combined medical and nursing management of Robert’s problems assisted him to achieve a relatively complication free admission. His ABG’s returned to normal indicating a resolution of the metabolic acidosis, blood electrolyte results were within normal range, renal function returned and no permanent cardiac problems ensued. He remained normotensive for the majority of his stay.

Considering Robert’s long history of drug abuse and his refusal of drug rehabilitation, there is a risk that he will return to his previous lifestyle when he is discharged from hospital. The rehabilitation process to regain the use of his leg will be extensive and it is still uncertain if he will be able to return to his previous employment. These factors combined with his poor social support network and noncompliant nature unfortunately jeopardise his long term prognosis.

Rhabdomyolysis is a clinical syndrome in which the contents of injured muscle cells leak into the circulation. This leakage results in electrolyte abnormalities, acidosis, clotting disorders, hypovolemia, and acute renal failure. More than 100 conditions, both traumatic and non-traumatic, can lead to rhabdomyolysis. Intervention consists of early detection, treatment of the underlying cause, volume replacement, urinary alkalinization, and aggressive diuresis or hemodialysis. Patients with rhabdomyolysis often require intensive care, and nurses are instrumental in both the early detection and the ongoing management of this life-threatening syndrome.

REFERENCES

Abassi A, Hoffman A, Better O. (1998) Acute renal failure complicating muscle crush injury. Seminar of Nephrology.18:558-565.

Better, O.S. (1990) ‘The crush syndrome revisited 19401990.’ Nephron, 55: 97-10

Burr, G. (1991) ‘Intensive care of the crush victim: Part I.’ Confederation of Australian Critical Care Nurses Journal, 4(2): 28-31.

Cheney P. (1994) Early management and physiologic changes in crush syndrome. Critical Care Nursing Quarterly. August 17:62-73.

Curry SC, Chang D, Connor D. (1989) Drug- and toxin-induced rhabdomyolysis. Annals of Emergency Medicine. 18:1068-1084.

Dayer-Berenson L. (1994) Rhabdomyolysis: a comprehensive guide. American Nephrology Nurses Association Journal.21:15-18.

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