NUR2023 Pathophysiology, Pharmacology, and Nursing Management Case Study 2 Sample
Case Study Details
Leonorah Jones is 26 years old and presents to the clinic with abdominal pain and urinary symptoms that have worsened over the last couple of days. She is now experiencing nausea and vomiting. On assessment, Leonorah indicates supra-pubic pain and appears to be guarding her abdomen, she states the pain gets worse when she moves.
Leonorah tells you she is feeling “sick” and has been vomiting since yesterday and now unable to tolerate any food or fluid. Today she is also feeling a “bit dizzy” when she stands up, has a sharp and almost constant pain in her “stomach” and at night has “shaking episodes like I am cold” despite feeling quite sweaty. She presents looking pale, unwell, and tired as she has been unable to sleep due to pain in her back and also having to get up and go to the toilet. She describes “sharp stinging pain” when she passes urine. Leonorah is teary and anxious – she tells you that yesterday her urine was pink/red but now it is just “smelly”; she provides a fresh urine sample today. She also divulges that she has had urine infections in the past but not like this. Leonorah denies being pregnant and states is sexually active however does not have a regular partner. She tells you that she practices ‘safe sex’ using a diaphragm most of the time.
You do some assessments and document the following :
• HR 116 beats per minute
• BP 101/71
• SpO2 Sats. 97% RA
• RR 24
• Temperature 38.6oC
• BGL 5.1mmol/L
• Pain 8/10
• Dry mucosa and lips
• Supra-pubic tenderness on palpation
• Non-distended abdomen, soft with tenderness [guarding] to LUQ and LLQ.
• Tenderness at the at the costovertebral angle with notable pain response
• Urine – Dark, cloudy, malodorous, pyuria?.
• SG 1.030, pH 7, Leucocytes +++, Nitrites +, Glucose -, Protein +, Bilirubin -, Ketones +, Blood +
• Oriented to person/place/time.
• Subjective: rigors described
Medical History : previous UTIs, nil other relevant
Current Medications: Nil.
Allergies - Nil known.
Social Background: Leonorah is a university student studying animal biology and wildlife management. She is single, lives alone in a 2 bedroom unit, works part time at a veterinary clinic. Sexually active, no regular partner. No recent overseas travel.
Update:
After multiple diagnostic tests including USS and CT, and pathology showing elevated WBCs, creatinine, and CRP, and confirmed positive urine culture; Leonorah has been diagnosed with Acute Pyelonephritis secondary to a urinary tract infection (Cystitis) and admitted to hospital for treatment.
Assignment 2 – TASKS ... you are required to complete ALL 4 tasks (and each bullet point).
TASK 1
PATHOPHYSIOLOGY
• Identify two (2) signs/symptoms that Leonorah is experiencing that are characteristic of her diagnosed condition. In your explanation, you must relate each sign/symptom you identified, back to the pathophysiological process (i.e. why is she experiencing the sign/ symptom) with evidence to support your reasoning.
• Identify the most common and likely infective pathogen in this case and briefly justify your decision.
TASK 2
PHARMACOLOGY
Note: nurses [generally] do not prescribe – however as an educated RN, you should have some knowledge of what medications may be charted. Medication competencies will be an annual requirement when you are a RN. Based on Leonorah’s presentation, the medical officer will obviously need to prescribe multiple medications.
• Identify two (2) priority medications that Leonorah will require. For each, explain why it is needed and also describe the pharmacodynamics.
o [Medication 1] must be a priority medication/treatment, based on her presenting condition.
o [Medication 2] will also be an important and essential medication.
• Identify one adverse effect of each, that you would need to assess, monitor or educate the patient about.
TASK 3
NURSING CARE
The following 3 nursing diagnosis/problems are identified by the RN for Leonorah:
1) Acute Pain
2) Impaired urinary elimination
3) ... (insert your own here. It could be an actual problem or risk of...) ...
For each nursing diagnosis for Leonorah, you will need to provide what it is related to and evidenced by, what are the goals you intend to achieve, what are two (2) nursing interventions to achieve this and what do you expect to be the outcome?
*Please use the following format/headings for this section:
Nursing Problem:
Related to:
Goal:
Nursing Intervention 1:
Rationale (supported by evidence-based practice)
Nursing Intervention 2:
Rationale (supported by evidence-based practice)
Evaluation/Outcome.
*if you find you are duplicating information from another question at any point, please reassess your approach to the question or discuss this with your tutor
TASK 4
CRITICAL THINKING ... mini essay.
(In this final task, a mini introduction of a couple of sentences and the same for concluding sentences at the end, are required)
Often elderly people (70+) may not present to their GP with “typical symptoms” of a urinary tract infection, this also includes elderly people in aged care settings potentially not being referred to a medical officer.
Briefly explore how, and why UTI symptoms may differ in the older adult leading to serious, and even potentially life threatening, conditions. Also, how might your nursing assessment change when assessing an elderly person for a urinary tract infection? In your discussion, you must provide evidence to support your answers.
Solution
Task 1: Pathophysiology
Two specific signs and symptoms experienced by Leonorah
The two significant symptoms Leonorah experienced that also represent the characteristics of her diagnosed condition include supra pubic tenderness and dark, cloudy and malodorous urine. As per the view of Hadian et al. (2020), Supra-pubic tenderness and guarding of the abdomen indicate abdominal discomfort and pain. In acute pyelonephritis, the infection typically starts in the lower urinary tract and then ascends to involve the kidneys. The pain and tenderness in the supra-pubic region are due to irritation and inflammation of the lower urinary tract. University Assignment Help, As the infection ascends to the kidneys, it causes inflammation and infection of the renal parenchyma (Swatesutipun, Srikuea, Wakhanrittee & Thamwongskul, 2021). Tenderness at the costovertebral angle CVA with notable pain response. As per the view of Paudel et al. (2022), CVA is a sign of kidney involvement in urinary tract infections, especially pyelonephritis. In acute pyelonephritis the bacteria ascends from the bladder to the kidneys, leading to inflammation and infection of the rental tissue. All such signs and symptoms represent severe conditions and require immediate action.
Most common pathogen
Urinary tract infections are recognised as one of the most common types of infections typically caused by bacteria, which Leonorah has experienced. UTI can be caused by various bacteria but one of the most common causative agents is Escherichia coli (E,coli). Cystitis is also an infection of the bladder caused by bacteria that travel up the urethra to the bladder. In addition to this, pyelonephritis is an infection of the kidneys and ureters, which is a much more serious condition. In addition to this, women are more susceptible to UTIs, and the infections tend to recur (Aggarwal & Jain, 2021). One of the major reasons that increases the risk of such infection is sexual intercourse. In the case of Leonorah, it has been identified that she is sexually active and practices safe sex using a diaphragm most of the time. This can be another reason behind suprapubic pain. As per the view of Scangarella-Oman et al. (2022), Pharmacodynamics is the most common antibiotic prescribed to treat UTIs caused by Ecoli including fluoroquinolones. These antibiotics work by inhibiting bacterial growth and replication. They target specific components of bacterial cells or interfere with essential bacterial enzymes, disrupting the bacteria's ability to proliferate and causing them to die. The most common side effects of these antibiotics are gastrointestinal disturbances, allergic reactions, elevated liver enzymes and headaches.
Task 2: Pharmacology
Two medications priority
One of the most important priorities for Leonorah is to provide adequate medications to reduce supra-pubic pain. The primary rationale behind this is experiencing of long-term supra-pubic pain that may lead to severe consequences and criticalness and may cause frequent need to urinate and sudden urges to urinate for at least six weeks. In this process, prescribing Leonorah with an analgesic, such as phenazopyridine would be essential (Shafrir et al. 2021).
In addition to this, another medication priority is to provide appropriate care and support for impaired urinary elimination. There are several signs and symptoms associated with Leonorah that represent a severe condition of impaired urinary elimination. Providing Leonorah with Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS), Fosfomycin (Monurol), Nitrofurantoin (Macrodantin, Macrobid, Furadantin), Cephalexin, Ceftriaxone can be helpful in this case (Hacad et al. 2022).
The rationale for continuous monitoring
In addition to this, urinary retention can be acute as well, and may lead to sudden inability to urinate at all or chronic conditions , a gradual inability to empty the bladder. In case the urinary tract does not empty, bacteria that normally enter the urinary tract are flushed out at the time of urination (Lin et al. 2021). In the case of Leonorah, it has been seen that her bladder is already infected which causes blood in her urine, which may create infection in her kidneys as well, if not treated properly.
Task 3: Nursing Care
Acute pain
Nursing problem: In the case of Leonorah, it is identified that one of the major symptoms being experienced is acute pain, which creates a significant level of discomfort and inability to sleep properly.
Related to: The acute pain being experienced by Leonorah, is directly related to constipation, irritable bowel syndrome (IBS), food poisoning and stomach virus as well. However, her symptoms are related to blood in urine indicating problems related to a bladder infection, which is recognised as gynaecologic pain.
Goal: The primary goal of this nursing intervention is to reduce the rate of pain as soon as possible as it may lead to several challenges in doing daily activities as well.
Nursing intervention 1: Gynaecologic pain has numerous and diverse causes. In addition to this, in the case of gynaecologic pain, the uterus, cervix, and adnexa share the same visceral innervation as the lower ileum, sigmoid colon, and rectum. Signals travel through the sympathetic nerves to spinal cord segment T10 through L1. The primary rationale behind this is, a shared pathway, distinguishing between pain of gynaecologic and gastrointestinal origin is often difficult. The first step of nursing care is the nursing assessment in getting diagnostic data. In the case of Leonorah, the pain level is 8/10 (Kyriakides, Jones, & Somani, 2021).
Rationale: The primary rationale is that there are some severe challenges associated with such pain. She is unable to do regular activities properly due to extreme pain in the back, and the level of pain also increases at the time of urination. Before evaluating the causes of the pain, it is essential to eliminate the pain to provide short-term support to Leonorah.
Impaired urinary elimination
Nursing problem: Impairments in urinary elimination in the case of Leonorah have taken place due to urinary retention and led to extreme pain and inability to pass urine properly.
Related to: Urinary issue is also recognised as overactive bladder, which refers to the involuntary loss of urine due to problems associated with controlling the bladder, which is frequently seen among women. This particular problem is primarily related to increasing feelings of embarrassment and a loss of independence as there are several issues related to this, such as wet clothing, urine odour and the requirement for assistance with toileting (Galfano et al. 2019).
Goal: The primary goal in handling this situation is to identify the major reasons behind such challenges and provide her with an appropriate care plan to reduce the chances of further consequences.
Nursing intervention 2: It is crucial to use critical thinking skills and select suitable interventions when offering patient-centred nursing care. For illustration, if a patient is suffering from acute respiratory distress, a suitable strategy will be required to deliver supplemental oxygen based on their SpO2 values, safeguarding safety and comfort. A nurse must offer patient-centred care by doing a thorough examination to discover potential causes when a patient appears with abdominal pain and urine symptoms (Bientinesi et al. 2022). A suitable solution includes administering pain relievers, such as analgesics, to ease discomfort whilst addressing urine symptoms that signifies a urinary tract infection. Following intervention, it is vital to closely examine pain alleviation and urine symptom resolution. Thus, evaluation, coordination with the healthcare team, and patient education on symptom management all contribute to safe, effective care and better patient outcomes.
Rationale: Leonorah will gain adequate knowledge and understanding demonstrating proper bladder emptying techniques that include double voiding and complete emptying of the bladder. Because of this, it will become easy to prevent urinary retention and reduce the risk of urinary tract infections, as evidenced by maintaining a post-void residual volume of less than 1 ml and reporting clear and odour-free urine (Saberi, Zargham, & Hayrabedian, 2021).
Bladder damage
Nursing problem: In case of Leonorah as identified that she has experienced UTI and problems related to urinary elimination for a long time the chances of developing bladder damage are significantly high.
Related to: The primary rationale behind this is that if urinary retention is not treated properly the bladder may be stretched too far or for long periods. Because of this, the muscles of the bladder may be damaged and work poorly.
Goal: The goal behind developing an appropriate intervention is to reduce the chances of further consequences related to bladder.
Nursing intervention 3: Looking for the reason behind such urinary elimination is also essential, targeting the cause to alleviate the pain is also essential to provide proper medication support to minimise further consequences, as severe urinary elimination can cause the risk of urinary tract infections as well.
Rationale: The presence of the symptoms of blood in the urine and painful urination associated with the case of Leonorah represents the potential for developing bladder damage and the absence of adequate treatment and medication support may make it quite challenging to improve her bladder condition, which can make the situation worse (Asikhia et al. 2022).
Outcomes: Leonorah's history of urinary tract infection (UTI) and chronic urine elimination difficulties increase her likelihood of having bladder damage greatly. This scenario has serious consequences, such as structural alterations to the bladder, and recurring UTIs. Long-term UTIs and their symptoms can also cause urine issues, renal issues, and chronic pain. To manage her illness, timely and appropriate nursing interventions are required which comprise antibiotic therapy to treat UTIs, and pain management to prevent additional infections. Continuous monitoring and coordination with healthcare experts are important for preventing bladder damage and enhancing Leonorah's overall quality of life.
Nursing Diagnosis: *chosen by student*: The nursing problem found in Leonorah with diabetes mellitus is an urine issue caused by diabetic neuropathy impairing bladder control. The intervention aims to understand the patient's livelihood by promoting continence. Thus, evaluating the severity and causes of nursing issues, teaching the patient about pelvic floor exercises and lifestyle changes, and creating a timed voiding plan are all nursing interventions. Thus, it will lessen the issue of Lenorah and help in overcoming the pain. The evaluation will boost the patient's self-esteem and independence.
Task 4: Critical thinking
Introduction
Urinary Tract Infection (UTI) is the most commonly found infection related to the excretory system of human beings. This may occur in persons of any age group. The following study deals with a critical overview of the specific conditions related to the disease and the complications associated with it.
The reason behind UTI symptoms differ in older adults leading to serious condition
The symptoms of UTI, a very common infection caused due to different age-related issues, vary in older generations from those found among younger women. The occurrence of UTI in elderly women in a community is higher among the post-menopausal category and patients with high diabetes risk (Gharbi, et al. 2019). There might not be any painful burning sensation during urination. The primary rationale behind this is that getting older may change the response to the immunity system of any individual. At the time of occurrence of UTI, the level of stress increases which can be affect both physical and mental health of an individual. Because of this, an older adult may become confused. Moreover, in case of an older woman who is suffering from Alzheimer's disease or dementia, the occurrence of UTI can make dementia temporarily worse (Santoso, & Kinesya, 2021).
Change in nursing assessment
In the context of handling cases of UTI in older women, diagnosing and treating the infection is relatively straightforward. Conducting a simple urinalysis can confirm the presence of infections and if someone is in proper health conditions, providing antibiotics would be the first choice of treatment. In addition to this, as a nursing professional encoraging patient to drink plenty of fluids may promote the flushing of bacteria from their systems. Proper fluid intake makes it harder for bacteria to live and multiply in the urinary tract. UTIs are more likely to affect people who attempt to manage stress by limiting the amount of water intake (Beeber et al. 2021). Hence, they do not have to go to the bathroom as much. However, this particular practice is significantly capable of increasing the risks of infection as the bacteria has the opportunity to build up and increase the complexity and severity rate continuously.
Meanwhile, in this context, the case of older adults who would require external support of a catheter in the urethra and bladder, along with diabetes and kidney stones might lead to several complexities in the process of handling UTIs. Hence, it is highly required that older adults living in group settings such as senior communities or nursing homes are likely to be resistant to the antibiotics most often prescribed for the disease (Godbole, Cerruto & Chavada, 2020). Changing the medications and taking some stronger medicines along with taking antibiotics for the long term can support handling the situation of the urinary tract infection as well.
Conclusion
The cases of UTI need to be taken seriously and treated with utmost care that might be specific to the individual patient. The nursing assessment discussed above would help in handling the patients accordingly.
References
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Asikhia, O., Durrani, M., Dugas, C., Cackovic, C., & Jerusik, B. (2022). Imperforate Hymen and Hematometrocolpos in a Female With Back Pain and Urinary Retention. Cureus, 14(10). https://www.cureus.com/articles/118127-imperforate-hymen-and-hematometrocolpos-in-a-female-with-back-pain-and-urinary-retention.pdf
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