Scenario 4: A 27-year-old Patient with Rhabdomyolysis
Scenario 4: A 27-year-old Patient with Rhabdomyolysis
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A 27-year-old patient presents with pain over his left hip and forearm, large amount of necrotic tissue over these areas as well as EKG abnormalities and hyperkalemia. The patient is experiencing rhabdomyolysis due to prolonged immobility after experiencing an opioid overdose. Rhabdomyolysis is a disease in which the muscle breaks down and releases intracellular muscle components such as creatine kinase and myoglobin into the bloodstream and has varying degrees of severity ranging from experiencing no symptoms to myoglobinuria, electrolyte imbalances and kidney failure (Zhong et al., 2020).
Normally at rest muscle cell ion channels on the plasma membrane keeps Na+ and Ca+ concentrations low within in the cell and high K+ concentrations in the muscle fibers. With muscle depolarization, Ca+ moves from the sarcoplasmic reticulum into the cytoplasm, which causes muscle cells to contract, and Adenosine triphosphate (ATP) is needed for this to happen. When the ion channels are damaged, intracellular electrolyte imbalances occur because there is too much Na+ and Ca+ in the cell. When there is too much Na+ in the cell, water is drawn into the cell. Too much Ca+ in the cell causes lysis of the cell membrane and damages the ion channels. These processes result in an inflammatory, unregulated digestion of the cells which causes necrosis of the muscle fibers and in turn releases creatine kinase and myoglobin into the blood stream (Torres et al., 2015).
The conclusion of rhabdomyolysis was made based on the symptoms of hyperkalemia, tissue necrosis, and muscle pain. In rhabdomyolysis, the muscle breaks down and releases potassium into the blood causing the patient to have hyperkalemia. A potassium level 6.5 or greater cause’s changes in EKG such as prolonged PR intervals and peaked T waves this patient had a potassium level of 6.9 which explains these changes. Tissue necrosis is caused by ischemia, introduction of toxins, infection, or trauma, which cause alterations in the cells after they die and begin to digest themselves. In this case, the patient may have been laying in an awkward position constricting circulation to their muscles on the left side of their body, or the patient may have been an intravenous drug user and developed an infection at the injection sites due to contaminated needles, or the drugs being injected may have been toxic to the muscle.
Naloxone was administered and the patient regained consciousness. Naloxone is a competitive opioid antagonist and works by blocking the receptors that opioids bind to in the brain so that temporarily, opioids can no longer be absorbed and the effects of the opioids on the individual are reversed (Shaw et al., 2019). This is why the patient regains responsiveness. If the patient had overdosed on a different drug or substance, the Naloxone would not have been effective leading to the determination that the patient was under the influence of opioids.
In this case, the patient is experiencing rhabdomyolysis due to prolonged immobility after experiencing an opioid overdose. However, rhabdomyolysis can be caused by factors such as infection, trauma, exercise, drugs, toxins, metabolic and electrolyte disorders (Nance & Mammen, 2015). Although RM has many different causes, all cases are characterized by elevated free ionized calcium in the cells causing the muscle cells to die due to the triggering of autolysis and sustained contraction of muscle fibers.
RM can be acquired through environmental factors as well as genetic factors. Genetic muscle defects cause rhabdomyolysis due to the muscle being unable to utilize ATP correctly and more energy is required than the amount being supplied which causes a disturbance of the membrane of the cell while exercising (Scalco et al., 2015). Genetic muscular disorders linked to RM are heterogeneous and rare (Scalco et al., 2015). For example, a genetic predisposition to malignant hyperthermia are more prone to viral RM, as well as patients who have muscular dystrophies and mitochondrial disorders are genetically predisposed to RM (Scalco et al., 2015). It is important to be aware of awareness of genotype-phenotype associations between genetic conditions and their relation to RM in order to correctly diagnose an RM occurrence because even if you are able to identify an environmental trigger does not mean there is no genetic cause as well (Scalco et al., 2015). If the patient had a history of muscular dystrophies, malignant hyperthermia or mitochondrial disorders, I would educate the patient on the risk for developing rhabdomyolysis and how to prevent it.
Scenario 4: A 27-year-old Patient with Rhabdomyolysis References
Nance, J. R., & Mammen, A. L. (2015). Diagnostic evaluation of rhabdomyolysis. Muscle & Nerve, 51(6), 793–810. https://doi.org/10.1002/mus.24606
Scalco, R. S., Gardiner, A. R., Pitceathly, R. D. S., Zanoteli, E., Becker, J., Holton, J. L., Houlden, H., Jungbluth, H., & Quinlivan, R. (2015). Rhabdomyolysis: A genetic perspective. Orphanet Journal of Rare Diseases, 10(1), 1–15. https://doi.org/10.1186/s13023-015-0264-3
Shaw, L. V., Moe, J., Purssell, R., Buxton, J. A., Godwin, J., Doyle-Waters, M. M., Brasher, P. M. A., Hau, J. P., Curran, J., & Hohl, C. M. (2019). Naloxone interventions in opioid overdoses: A systematic review protocol. Systematic Reviews, 8(1), 1–9. https://doi.org/10.1186/s13643-019-1048-y
Torres, P. A., Helmstetter, J. A., Kaye, A. M., & Kaye, A. D. (2015). Rhabdomyolysis: pathogenesis, diagnosis, and treatment. The Ochsner journal, 15(1), 58–69.
Zhong, H.-, Zhao, G.-, & Guo, P.-. (2020). A case of rhabdomyolysis with compartment syndrome in the right upper extremity. World Journal of Emergency Medicine, 11(3), 185. https://doi.org/10.5847/wjem.j.1920-8642.2020.03.010
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Scenario 4: A 27-year-old patient with a history of substance abuse is found unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. Patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.
Discussion: Alterations in Cellular Processes
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At its core, pathology is the study of disease. Diseases occur for many reasons. But some, such as cystic fibrosis and Parkinson’s Disease, occur because of alterations that prevent cells from functioning normally.
Understanding of signals and symptoms of alterations in cellular processes is a critical step in diagnosis and treatment of many diseases. For the Advanced Practice Registered Nurse (APRN), this understanding can also help educate patients and guide them through their treatment plans.
For this Discussion, you examine a case study and explain the disease that is suggested. You examine the symptoms reported and explain the cells that are involved and potential alterations and impacts.
To prepare:
- By Day 1 of this week, you will be assigned to a specific scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
By Day 3 of Week 1
Post an explanation of the disease highlighted in the scenario you were provided. Include the following in your explanation:
- The role genetics plays in the disease.
- Why the patient is presenting with the specific symptoms described.
- The physiologic response to the stimulus presented in the scenario and why you think this response occurred.
- The cells that are involved in this process.
- How another characteristic (e.g., gender, genetics) would change your response.
Read a selection of your colleagues’ responses.
By Day 6 of Week 1
Respond to at least two of your colleagues on 2 different days and respectfully agree or disagree with your colleague’s assessment and explain your reasoning. In your explanation, include why their explanations make physiological sense or why they do not
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Scenario 4: A 27-year-old Patient with Rhabdomyolysis Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion
Assignment
Practicum Manual Acknowledgment
The Practicum Manual describes the structure and timing of the classroom-based and practicum experiences and the policies students must follow to be successful in the nurse practitioner (NP) specialties.
Click here and follow the instructions to confirm you have downloaded and read the entire MSN Nurse Practitioner Practicum Manual and will abide by the requirements described in order to successfully complete this program.
What’s Coming Up in Week 2?
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Next week, you will examine alterations in the immune system and the resultant disease processes. You will also consider patient characteristics, including racial and ethnic variables, that may impact altered physiology.
Practicum – Upcoming Deadline
In the Nurse Practitioner programs of study (FNP, AGACNP, AGPCNP, and PMHNP) you are required to take several practicum courses. If you plan on taking a practicum course within the next two terms, you will need to submit your application via Meditrek .
For information on the practicum application process and deadlines, please visit the Field Experience: College of Nursing: Application Process – Graduate web page.
Please take the time to review the Appropriate Preceptors and Field Sites for your courses.
Please take the time to review the practicum manuals, FAQs, Webinars and any required forms on the Field Experience: College of Nursing: Student Resources and Manuals web page.
- Field Experience: College of Nursing Quick Answers
- Field Experience: MSN Nurse Practitioner Practicum Manual
- Student Practicum Resources: NP Student Orientation
Next Week
RE: Main Post Week 1
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Main Post – Week 1
The patient is presenting with the symptoms of burning pain over his hip and forearm because he has a pressure injury to those areas caused by the constant pressure of lying on the floor for an extended amount of time causing decreased blood flow and oxygen supply to the areas that had constant pressure applied (McCance & Heuther, 2019). The patient had impaired circulation and tissue perfusion, was immobile, was probably undernourished, and had decreased sensation due to substance abuse, all of which are risk factors for developing pressure ulcers (Grada & Phillips, 2019). Once he received naloxone, he became responsive and was able to feel pain to the areas where the pressure injuries had occurred.
The hyperkalemia was caused by a shift of potassium from the intracellular fluid to the extracellular fluid due to cell hypoxia changing the permeability of the cell membrane (McCance & Heuther, 2019). The cells involved in this process are keratinocytes, Langerhans cells, Merkel cells, macrophages, mast cells, histiocytes, and fibroblasts. If the patient was genetically predisposed to weakening skin conditions, the rate of cell death could be much faster, leading to a greater morbidity and mortality of pressure ulcers. This patient’s morbidity and mortality risk would also be increased due to his substance abuse.
Scenario 4: A 27-year-old Patient with Rhabdomyolysis References
Grada, A., & Phillips, T. J. (2019). Pressure Ulcers. Retrieved from Merck Manual: https://www.merckmanuals.com/professional/dermatologic-disorders/pressure-ulcers/pressure-ulcers
McCance, K. L., & Heuther, S. E. (2019). Pathophysiology the biologic basis for disease in adults and children(8th ed.). Elsivier, Inc.
Lopes Write Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource