Scenario 4 27 Year Old With Substance Abuse History Found Unresponsive

Scenario 4 27 Year Old With Substance Abuse History Found Unresponsive

 

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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.

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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

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.

• Field Experience: MSN Nurse Practitioner Practicum Manual

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.

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• Student Practicum Resources: NP Student Orientation

Next Week

To go to the next week:

Week 2

 

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.

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.

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