Assessment 2: Case Study Analysis of Mr. Kirkman's Critical Condition

This case study analyzes the clinical presentation and management of Mr. Kirkman, a 75-year-old male admitted to the emergency department with symptoms of a urinary tract infection (UTI) and lower abdominal pain. The analysis focuses on the pathogenesis of his symptoms, including elevated heart rate, fever, reduced blood pressure, and abnormal respiratory rate, linking these to urosepsis and the body's inflammatory response. The study explores the role of bacterial infection, the impact of smoking and alcohol consumption, and the influence of the renin-angiotensin-aldosterone system (RAAS) on his condition. The selected nursing strategy involves antibiotic treatment and phenazopyridine administration to alleviate UTI symptoms. Additionally, the arterial blood gas results are critically analyzed, demonstrating the presence of metabolic acidosis, tissue hypoperfusion, and organ dysfunction, all related to the urosepsis. The study emphasizes the need for immediate interventions to prevent further health deterioration and references relevant literature to support the analysis.

Running head: CASE STUDY
Assessment 2
Name of the Student
Name of the University
Author Note

1CASE STUDY
Introduction- Critical care nurses are entitled with the responsibility of providing
treatment modalities to patients who have been identified as acutely ill, and require
conduction of regular nursing assessments, thoroughly the implementation of effective
medications and/or life sustaining technology and drugs. The case study is based on Mr
Kirkman, a septuagenarian, who recently got admitted to emergency department of the
hospital, following manifestations of signs and symptoms that comprised of burning
sensation during urination, apart from pain in the lower abdomen, which radiated to his right
flank. Moreover, he had been diagnosed with urinary tract infection (UTI) and was under the
day-to-day administration of IV NaCl and IV Sulfamethoxazole-trimethoprim. Insertion of
indwelling catheter was another notable sign. This case study will analyse the pathology of
his clinical manifestations.
Clinical manifestation pathogenesis- Following admission of the patient to the
healthcare setting, a comprehensive physical assessment had been conducted, which provided
information on the presence of an unusually raised heart rate. In addition, the patient also
reported signs and symptoms of increased body temperature, reduced blood pressure, poor
levels of oxygen saturation, and an elevated respiratory rate. On analysing his presenting
complaints, it can be suggested that the patient was suffering from Urinary Tract Infection
(UTI) that generally occurs when pathogens such as, bacteria (Klebsiella or Escherichia coli)
enter the urinary bladder, primarily through the urethra (Walsh & Collyns, 2017).
Homeostasis refers to the tendency of the human body to maintain a state of equilibrium,
while adjusting the biological system to the physiological conditions that are considered
optimal for human survival. There is mounting evidence for the fact that natural resistance is
manifested by the body, in relation to changing conditions that helps in maintaining
homeostasis (Kotas & Medzhitov, 2015). The elevation in respiratory rate and pulse rate can

2CASE STUDY
be cited as a mechanism of homeostasis, in relation to pro-inflammatory response of the
body.
Time and again it has been proved that the immune system plays an important role in
maintaining homeostasis by fighting off infections, thereby protecting the body (Honda &
Littman, 2016). During onset of an infection, the immune system releases pyrogens that send
signals to the brain for increasing the temperature of the body, thereby causing fever. Hence,
high body temperature, as manifested by Mr Kirkman can be associated with pyrogen release
since they result in release of PGE2 or prostaglanding E2 that subsequently acts on
hypothalamus and causes heat-generating impacts on the body by creating systemic response
(Brito et al., 2016). Furthermore, pro-inflammatory cytokines like tumour necrosis factor
(TNF) and interleukin (IL)-1 also produce fever in an individual (Eskilsson et al., 2017). It is
a well-established fact that balance between anti-inflammatory and pro-inflammatory
cytokines is imperative for maintaining optimal health. However, pro-inflammatory
mediators have also been associated with inflammation in heart vasculature, thereby
activating the immune cells, and increasing the heart rate in the patient. Mr Kirkman was an
active smoker (Müller-Werdan, Prondzinsky & Werdan, 2016).
There is mounting evidence for the correlation between smoking and dysfunction of
the heart, which in turn increases chances for tachycardia (Linneberg et al., 2015). Taking
into consideration the fact that the patient was an alcoholic, it might have resulted in
electrical signal disruption, thus creating an impediment in the production of normal
heartbeat. Tachypnoea or increased respiratory rate in the patient can be associated with the
fact that there was a possibility of the pathogens getting dispersed all across the body, and
eventually affecting the lungs that lead to an activation of cytokine IL-1β
facilitated inflammatory cells (Hogmalm, Bry & Bry, 2018). In addition, C5a present in
neutrophils acts in the form of stimulant for chemokine and pro-inflammatory cytokine

3CASE STUDY
release that also resulted in inflammatory response, which in turn can be associated with
tachypnoea.
Untreated UTI can also be correlated with spread of the bacterial infection that
subsequently results in sepsis development amid patients, which in turn is often manifested
with mild, moderate or severe pain. Hence, the abnormalities in the clinical manifestations
can be characterised as a sign of urosepsis owing to the fact that trauma or infection triggers
release of pathogens and intrinsic signalling molecules that are eventually identified by
receptors located on endothelium, or complement system, thus modulating immune responses
(Peach et al., 2016). In addition, it can also be stated that urosepsis is mediated by cytokine
release and is concomitant with a reduction in systemic vascular resistance, which
subsequently leads to the onset of vasodilation.
The renin–angiotensin–aldosterone system (RAAS) plays an important role in
governing balance between body fluids and electrolytes. Owing to the fact that angiotensin II
acts in the form of a potent vasoconstrictive peptide that brings about narrowing or
constriction of blood vessels, thus causing hypertension, it can be suggested that an
impairment in renal functioning created an impact on RAAS (Romero, Orias & Weir, 2015).
Thus, failure of RAAS in increasing extracellular fluid volume in the body was responsible
for vasodilation. Decrease in blood pressure can also be associated to entry of pathogen in the
circulating blood that has often found to result in anaphylactic shock. This condition is
primarily characterised by a life-threatening and severe allergic reaction that occurs due to
cytokine and inflammatory mediator release from basophils and mast cells, due to
immunologic reaction (Gaieski & Mikkelsen, 2018). Enzymes present in bacteria often covert
nitrites to nitrates. Hence, elevated levels of nitrate in his urine suggested the presence of
bacterial infection. Furthermore, increased level of creatinine indicated that that they was

4CASE STUDY
malfunction in the renal system, in relation to waste removal from the body, thus increasing
concentration of urea.
Furthermore, diagnosis of UTI also blocked the urinary tract, thus leading to
impairment in renal function, and lowering the urine output. Low urine output can also be
linked with bladder inflammation that acted as a barrier in the normal process of bladder
emptying. Presence of burning sensation as experienced by Mr Kirkman can be related to
bacterial infection, thus confirming urosepsis. He also reported dark coloured urine that
hinted at the presence of toxic and harmful wastes in blood circulation due to the infection
(Kobayashi, Hayakawa & Kato, 2016). Furthermore, the amount of leucocyte was also high,
thus confirming infection. Blood cell leakage or haematuria is a common UTI sign. Hence,
impairment in renal function might have led to the condition (Buteau et al., 2014).
Nursing strategy- There is mounting evidence for the fact that presence of a heart rate
more than 130 beats/minute, respiratory rate more than 30 breaths/minute, systolic blood
pressure less than 90, oxygen saturation less than 90 and temperature more than 37.5 are
categorised into the yellow flag for CEC calling criteria (NSW Government, 2014). The
patient will be subjected to antibiotic treatment whereby, the medication
phenazopyridine will be administered to reduce the signs and symptoms of UTI. Upon being
excreted in urine, this medication will create a local analgesic impact and reduce the pain,
and infection severity (Propst et al., 2016). In addition, it would also provide immediate relief
from the burning sensation that the patient reports during urination.
Arterial blood gas results- Increase in lactate levels in bloodstream suggests that the
patient was suffering from urosepsis since a decrease in the concentration of oxygen leads to
carbohydrate breakdown for releasing energy, thereby causing lactate accumulation, and
leading to organ dysfunction (Nikolaidis et al., 2016). Low pH also suggested the presence of

5CASE STUDY
academia in the patient due to metabolic acidosis that commonly occurs at the time of sepsis
and leads to excess acid production due to renal failure in removing wastes from the body. In
addition, increase in the serum lactate levels also suggested that Mr Kirkman was suffering
from tissue hyperfusion that is characterised by insufficient delivery of nutrients and oxygen
to the body cells and tissues (Casserly et al., 2015). Reduced bicarbonate amount and low
partial pressure of oxygen also confirmed tissue hyperfusion.
Conclusion- To conclude, on analysing the case study of Mr Kirkman, he is found to
be suffering from urosepsis and needs immediate interventions for preventing deterioration of
the health condition.

6CASE STUDY
References
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TNF-α, IL-6, and PGE2 in endogenous pyrogen-induced fever. Journal of
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Gaieski, D. F., & Mikkelsen, M. E. (2018). Evaluation of and initial approach to the adult
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Hogmalm, A., Bry, M., & Bry, K. (2018). Pulmonary IL-1β expression in early life causes
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Physiology-Lung Cellular and Molecular Physiology, 314(6), L936-L945.

7CASE STUDY
Honda, K., & Littman, D. R. (2016). The microbiota in adaptive immune homeostasis and
disease. Nature, 535(7610), 75.
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