You are the Intake/Booking nurse when Mr. Ramus is arrested and brought to the county jail on Friday evening. He is 28 years old, denies any medical or mental health history, but does admit to using alcohol and methamphetamines “recreationally” for “a while”. When asked to define “recreationally,” he states, “you know, a little every day …. for fun. I am definitely not addicted!” With further questioning from you, he admits that his recreational use of methamphetamine got “a little out of hand” last week, and he actually had been on a 4 day binge when he got arrested. He tried to use the alcohol to “slow down” and so was arrested for being passed out at the park. He did not know how long he had been passed out, but the last he remembered, it was Wednesday night. His vital signs are as follows: blood pressure 138/86, pulse 110, respirations 18, oxygen saturation 98%, temperature 98.9°F, blood glucose 96 (via finger-stick).
It’s difficult for Mr. Ramus to sit still, and he, in fact, is pacing in the intake room while you are conducting the Receiving Screening.
You decide, based upon his disclosure and presentation, that Mr. Ramus needs to be monitored for potential alcohol withdrawal, and per your policy, he is housed in Booking under medical observation. There is no formal monitoring done at your facility for methamphetamines*. CIWA-ar monitoring is initiated, with his first score being 11 (anxiety and restlessness).
The Next Day (Day 2 of Incarceration)
The next day Mr. Ramus is complaining of body aches, especially his calves, and feeling weak when the nurse comes to Booking to do his monitoring in the afternoon. He denies a history of opiate use. He is told to increase his fluid intake. His vital signs are as follows: blood pressure 128/76, pulse 118, respirations 18, oxygen saturation 98%, temperature 99.6°F, blood glucose 84, CIWA-ar score 6.
At this facility, CIWA-ar monitoring is done three times a day for 3 days, and if the patient is not over a CIWA-ar of 9, it is reduced to twice a day for another 3 days*. His CIWA-ar score from the overnight shift was 8.
Later that evening, when his CIWA-ar monitoring is being done, Mr. Ramus states that he is feeling nauseated, and the feeling of weakness is worse. In addition, his body aches are now in his back and upper arms. He discloses that he tried to do some exercise earlier, thinking that his muscles ached because he was not able to move around in his cell like he would have if he was not in jail, but he was too weak and now his legs hurt when he touches them. The nurse asks him again if he has been taking opiates on the outside. This time, Mr. Ramus becomes agitated and yells at the nurse, but continues to deny any involvement with opiates. He refuses vital signs and tells the nurse to leave. The nurse tells Mr. Ramus that he is just having a “bad detox” and to continue to drink lots of fluids. She tells him he also should not be exercising at this time. She tells him that she will come back later to try to get the vital signs and conduct the CIWA-ar assessment, but she does not make it back.
The Next Day (Day 3 of Incarceration)
Around 0700 hours the next day, Mr. Ramus starts to yell out in Booking that he has to get out of there to get his basketball equipment. He is belligerent and very agitated. The officers call you to evaluate Mr. Ramus and tell you that this is a significant change in behavior for Mr. Ramus. You remember him from when he arrived 2 days ago. Mr. Ramus tells you about the basketball tournament he is in, and that he has to be at the court in an hour for practice. He asks if you can help him get out.
When you ask him where he thinks he is, he states, “at the hospital – you’re a nurse, right? I must be at the hospital.” He does allow you to obtain vital signs, which include the following: blood pressure 112/64, pulse 132, respiration 22, oxygen saturation 96%, temperature 101.3°F, CIWA-ar 15. He also allows you to conduct a physical assessment, and your findings are below:
- Gait steady, speech clear, alert and oriented X 1 (person),
- mental status confused
- Skin warm, slightly diaphoretic on face, otherwise dry
- Lungs clear bilaterally without adventitious sounds
- Heart rate regular, tachycardic, no murmurs or gallops heard
- Abdomen soft, non-tender to palpation x 4 quadrants; + bowel sounds x 4 quadrants
- Bilateral lower legs (calves) +2 tender to palpation; right calf +1 non-pitting edema; pedal strength =, 4/5 bilaterally with c/o increased pain during testing; calf muscles feel “doughy”
- Bilateral upper extremities biceps +2 tender to palpation and +1 tender with movement; hand-grasp strength = and 5/5 with c/o increased pain during testing
Mr. Ramus also tells you that something is “really wrong” because he is peeing coca cola, and “they don’t give us that here.” He is able pee in the specimen cup, and it is very dark.
You immediately call the provider on-call, who orders an intravenous line with normal saline and to send Mr. Ramus out (911) to the emergency department.
At the Hospital
At the hospital, Mr. Ramus is diagnosed with rhabdomyolysis due to alcohol and methamphetamine use. The symptoms exhibited by Mr. Ramus over the last two days are the result of the muscle cell breakdown and the electrolyte imbalances that occurred as a result of the mismatch between energy production and energy consumption from his most recent methamphetamine binge and the muscle damage done when he was immobile while intoxicated. Mr. Cushing is treated at the hospital for four days, then returns to the jail.
For more information about Rhabdomyolysis, search at CorrectionalNurse.Net where there are some monthly posts about Rhabdomyolysis. Also check out The Correctional Nurse Educator accredited class entitled, Rhabdomyolysis for the Correctional Nurse.
Please share any experiences you have had in your practice with patients presenting with rhabdomyolysis in our comments section, below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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