Health Variations 4: Urosepsis Case Study Analysis and Nursing Care

This case study analyzes a 75-year-old male patient, Mr. Kirkman, who presented to the emergency department with symptoms indicative of a urinary tract infection (UTI). The assignment explores the pathogenesis of urosepsis, detailing how bacterial infection progresses from urethritis and cystitis to sepsis, and the body's immune response. It examines the clinical manifestations, including burning sensation upon urination, lower abdominal pain, fever, and respiratory distress. The study also identifies and justifies an appropriate nursing strategy, oxygen therapy, based on the ABCDE framework, and analyzes the patient's arterial blood gas (ABG) results, relating them to the underlying physiological changes caused by sepsis, such as respiratory failure and metabolic acidosis. The analysis highlights the abnormal values in the ABG results, including low partial pressure of oxygen, low partial pressure of carbon dioxide, and abnormal levels of lactate, bicarbonates, and base excess, all of which are linked to the patient's condition and the systemic effects of sepsis.

Running head: A CASE STUDY ON UROSEPSIS 1
A case study on urosepsis
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A CASE STUDY ON UROSEPSIS 2
Question 1: Analyze the pathogenesis in relation to the clinical manifestations in the case
study.
20-30% of sepsis according to recent studies, are due to urinary tract infections. A urinary
tract infection (UTI) according to both the World Health Organization and the Centre for Disease
and Control is alteration to the urinary system such it is unable to eliminate urine from the body
effectively (Singer,Deutschman & Seymour,2016).The components of the urinary system include
bladder, ureters and the urethra. All these components according to Abraham are sterile and it’s
difficult for any pathogen or foreign agent under normal conditions to invade (Abraham, 2016).
However, in extreme conditions like unprotected sexual intercourse and unhygienic insertion of
indwelling catheters, the bacteria, mostly gram negative can invade the urinary system. Rarely
can bacteria from the colon get access to the urinary system. The bacteria then multiply
randomly in the urethra leading to a condition known as urethritis (Sprung & Reinhart, 2016). If
at this point the bacteria are not controlled, they move to the bladder and randomly multiply
leading to cystitis. Multiplication of bacteria in the bladder and urethra is responsible for the
itchy or burning sensation as experienced by Mr. Kirkmann. The patient can also experience
lower abdominal discomforts with pain radiating from the right flank if the bacteria multiply in
the bladder. At this stage, it is easy to combat the bacteria by using antibiotics. However, it is
important to carry out culture test to identify the type of bacteria and then carry out a sensitivity
test to find out the best antibiotic to be used. Failure to treat the UTI at this stage, the patient is at
risk of severe complication such as sepsis.
Sepsis, according to numerous studies is an immune response of the body that might
injure some of the vital organs of the body. In one study, results show that the gram negative
bacteria such as klebsiella, proteus, and E.coli and staphylococcus aureus have

A CASE STUDY ON UROSEPSIS 3
lipopolysaccharides in their cell walls. It is the endotoxin lipopolysaccharide that is responsible
to mediate or activate the immune system (Tandogdu, Bjerklund Johansen, Bartoletti, &
Wagenlehner, 2016). The study established that this endotoxin activate the different components
of the immune system such as monocytes, dendritic cells, macrophages, inflammatory and the
coagulation and complement systems. Besides mediating clinical sepsis, studies elaborate that
monocytes produce tumor necrosis alpha and interleukin 1 at different concentrations. Response
of the immune system according to studies results to inflammation and injury to vital organs
such as the heart and the lungs (Deutschman & Singer, 2016). Inflammation leads to high
temperature and that is why Mr.Kirkmann had fever. Injury to organs also leads to high levels of
coagulation factors like platelets as seen in the diagnosis of Mr.Kirkmann. Furthermore, injury to
vital organs like lungs and heart lead to respiratory failure and that is why Mr.Kirkmann
experience high heart and breathing rates of above 90 beats and 20 breathes per minute
respectively. Respiratory failure also leads to low blood pressure and in this case study, it was
80/42mmHg.Tissue perfusion due to sepsis leads to metabolic acidosis and that is why there
were abnormal values in arterial blood gases.
Question 2: Appropriate nursing strategy
The appropriate nursing strategy for the case of Mr.Kirkmann is oxygen therapy. Based
on the ABCDE framework of nursing assessment, the health problem to be given the first
priority is difficulty in breathing. Mr.Kirkmann is finding it hard to breath. This can be seen
through a high breathing and heart rate (Gerlach, 2018). Studies note that sepsis leads to
respiratory failure leading to tissue perfusion. In this case, the objective of oxygen therapy is to
provide extra oxygen so as to optimize the functioning of vital organs and tissues. The nurse in
this case should administer highly concentrated oxygen. Before administration however, the

A CASE STUDY ON UROSEPSIS 4
nurse should record oxygen saturation sometimes referred to as the 5th vital sign. This can be
achieved through pulse oximetry. The other important signs include pulse, blood pressure,
temperature and finally the respiratory rate. Furthermore, oxygen should be administered to
reach the recommended 94-98% saturation. In this case, oxygen is supposed to be administered
by an experienced staff with the help of appropriate devices and at a desirable flow rate to obtain
the desired oxygen saturation. Once the desired oxygen saturation has been achieved, the nurse
should then cross off the drug chart after discontinued administration.
Question 3: Analysis of arterial blood gases
An arterial blood gas test is routinely carried out in the Intensive care department and the
ER setting where the patients are experiencing difficulties in breathing. This test is carried out to
find out the PH, oxygen, lactate, base excess and carbon dioxide levels in circulation. The
rationale is to find out if the lungs are effective or not. However, an arterial blood gas is not only
limited to the Intensive Care Department (Rather & Kasana, 2015). The test can also be
conducted depending on the diagnosis of the patient like in the case of Mr. Kirkmann. A full
arterial blood gas profile is composed of PH, partial pressure for both oxygen and carbon
dioxide, lactate, bicarbonates and the Base excess. The International Quality Assurance has
conducted several trials across the world and come up with normal ranges of the particular
parameters of the arterial blood gases. However, these values may vary depending on altitude.
The normal range for PH should be between 7.35 and 7.24.The normal partial pressure for
carbon dioxide should be between 35 and 45 mmHg while that of oxygen is estimated to be
between 75 and 100 mmHg. Those of Bicarbonates is 22 and 26 mEq/L .Finally, the
recommended or normal values for base excess is between -2 and +2 mmol/L. The values for
lactate is between 0.3 and 0.8 mmol/L.

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Certain physiological abnormalities may lead to discrepancies in arterial blood gases like
it was the case for Mr.Kirkmann. All the values in this case were outside the normal ranges and
is due to an interplay of different factors. The World Health Organization define sepsis as an
immune response to an underlying condition. The response is associated with certain
hemodynamic changes as well as the respiratory failure. A partial pressure oxygen test is
conducted to find out how well oxygen is circulating through the body from the lungs to tissues
(Seymour et al., 2016). Since sepsis brings about hemodynamic changes and respiratory failure
however, this means that less oxygen moves from the lungs to tissues and this why the partial
pressure for Mr.Kirkmann in the case study was below the normal range at 75 mmHg. A partial
pressure for carbon dioxide test is done to find out how well tissues get rid of carbon dioxide.
With tissue perfusion in sepsis however, less carbon dioxide is eliminated and this is why the
partial pressure for carbon dioxide in the case study was below the normal ranges (Shankar-Hari
et al., 2016). Under normal circumstances, the cells use oxygen during aerobic metabolism to
produce energy for cells. In sepsis, tissue perfusion means oxygen is unavailable. The cells
therefore metabolize carbohydrates and amino acids through anaerobic respiration. Lactate
dehydrogenase is the enzyme that breaks down pyruvate to produce lactic acid. This leads to a
buildup of lactic acid in blood that causes low PH of 7.25 in the case of Mr.Kirkmann. With
increased lactic acid, it tips the acid base balance leading to low Bicarbonates, base excess which
was exhibited in the case of Mr.Kirkmann at 3.2 mmol/L and -6mmol/L respectively.

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References
Abraham, E. (2016). New Definitions for Sepsis and Septic Shock. JAMA, 315(8), 757.
doi:10.1001/jama.2016.0290
Deutschman, C. S., & Singer, M. (2016). Definitions for Sepsis and Septic Shock—Reply.
JAMA, 316(4), 458. doi:10.1001/jama.2016.6389
Gerlach, H. (2018). Faculty of 1000 evaluation for Assessment of Clinical Criteria for
Sepsis: For the Third International Consensus Definitions for Sepsis and Septic
Shock (Sepsis-3). F1000 - Post-publication peer review of the biomedical literature.
doi:10.3410/f.726165855.793550942
Rather, A. R., & Kasana, B. (2015). The Third International Consensus Definitions for
Sepsis and Septic Shock (Sepsis-3). JMS SKIMS, 18(2), 162-164.
doi:10.33883/jms.v18i2.269
Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., …
Angus, D. C. (2016). Assessment of Clinical Criteria for Sepsis. JAMA, 315(8), 762.
doi:10.1001/jama.2016.0288
Shankar-Hari, M., Phillips, G. S., Levy, M. L., Seymour, C. W., Liu, V. X., &
Deutschman, C. S. (2016). Developing a New Definition and Assessing New Clinical
Criteria for Septic Shock. JAMA, 315(8), 775. doi:10.1001/jama.2016.0289
Singer M, Deutschman CS, Seymour C.(2016).The third international consensus definitions
for sepsis and septic shock (sepsis-3). JAMA 2016;315(8):801-810.
Sprung, C. L., & Reinhart, K. (2016). Definitions for Sepsis and Septic Shock. JAMA,
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Tandogdu, Z., Bjerklund Johansen, T. E., Bartoletti, R., & Wagenlehner, F. (2016).
Management of the Urologic Sepsis Syndrome. European Urology Supplements,
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