Module 1 Assignment: Case Study Analysis NURS 6501

Module 1 Assignment: Case Study Analysis NURS 6501

Introduction

This study is based on the underlying condition of a 42-year-old patient who has been presenting in the emergency department with redness, swelling, and pain in his right calf. The patient history indicates that he had developed a cut with the string trimmer while working in the yard, and he has cleaned it with water from the garden hose. He also covered it with a large bandage. After a few days, he developed a high fever and reaches the ED for care. The patient needs immediate care, resulting in the development of adverse effects like organ dysfunction, etc. This study constitutes how the signs and symptoms developed, followed by the genes associated and the process of immunosuppression.

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System Development

The patient had developed a wound infection which, if not managed, can result in septic disease. The wound constituted of germs and bacteria, and the patient had not cleaned this sufficiently. The bacteria grew under the damaged skin spreading to sensitive tissues present. As a result of the infection, the inflammatory response has stimulated, and inflammatory molecules are released. These inflammatory mediators like white blood cells (WBCs) further produce free radicals and enzymes, resulting in tissue damage and nerve damage.

Therefore, pain is generated, which is caused by the stimulation of pain receptors. The wound site develops a swelling due to the excess movement of white blood cells and fluid into the injured area. The infected tissues and nerves are put under extra pressure with the swelling and causing pain. The formation of wound clots is also an inflammatory response of the body, so the site becomes red (Stone, Basit & Burns, 2020).

During an infection, the body makes up an excess of inflammatory cells, which are the WBCs that work effectively to kill the bacteria. In addition, the increased production of white blood cells may affect the hypothalamus, which shifts the average body temperature upwards. It occurs as the bacteria releases pyrogens in the body, generating the immune response (Prajitha, Athira & Mohanan, 2018; Balli & Sharan, 2020).

Genes That Associated with The Development of The Disease

The genes that are associated with the development of the infection include IL4, IL10, and NRAMP1. As a result of the disease from the bacteria, the inflammatory response is generating by interleukins like IL6, etc. The interleukin genes of IL4 and IL10 producing cytokines induced to make the anti-inflammatory response, restoring the balance after the cytokines storm. The IL4 is present in the eosinophils, basophils, and Th2 cells. The IL10 plays a central role in the development of the anti-inflammatory response and maintaining homeostasis. Both the genes, IL4 and IL10, are pleiotropic. They are also known to produce inflammatory responses, but they recruit to produce anti-inflammatory cytokines when controlling hyper inflammation. The proteins produced by IL4 and IL10 directly suppress the role of Th1 cells (Nedelopoulou et al., 2020). The NRAMP1 gene produces the NRAMP1 protein, an integral membrane protein expressed in the lysosome activity inducing cells macrophages and monocytes. However, the NRAMP1 is also known to have pleiotropic effects and is the gene responsible for producing disease resistance and can lead to the development of immunosuppression (Known, Jo & Park, 2018).

The Process of Immunosuppression and The Effect It Has On The Body Systems

Patients who do not have the ability or have reduced capacity for fighting bacteria and other microorganisms in the body. A cytokine-mediated inflammatory response had seen during a sepsis infection resulting in a hyper-inflammatory phase (Cytokine storm) followed by the immunosuppressive phase. Sepsis infection had characterized by the excess production of cytokine-mediated inflammatory mediators. Some evidence also suggests that the body also generates anti-inflammatory compounds as the inflammatory mediators are extra.

Immunosuppression can be caused due to various reasons like an underlying disease, age, genetics, medication, and surgery. The infection of sepsis activates the apoptosis of cellular B and T cells which are immune cells. As the apoptotic cells induce the activation of the dendritic cells, they have an increased role in the anti-inflammatory response in sepsis. The apoptosis of T cells further induces the downregulation of the CD4+ and CD8+ cells. This process is known as autophagy and contributes to immunosuppression. As the body’s immune cells are hyperactive, the cells also become exhausted, which can cause immunosuppression (Ono et al., 2018).

Conclusion

The patient presented to the emergency department has developed a wound infection, and there was a need for immediate management. As a result of the condition, the patient developed signs of pain, inflammation, and high fever, indicating sepsis. Sepsis results in immunosuppression which has multiple mechanisms like apoptosis of the immune cells. The genes responsible for the development of sepsis include NRAMP1, IL4, and IL10. Therefore, understanding these aspects of sepsis will make infection management easier for the nurse and reduce further risk.

References

Balli, S., & Sharan, S. (2020). Physiology, Fever (Hyperthermia). StatPearls [Internet].

Kwon, H. K., Jo, W. R., & Park, H. J. (2018). Immune-enhancing activity of C. militaris fermented with Pediococcus pentosaceus (GRC-ON89A) in CY-induced immunosuppressed model. BMC complementary and alternative medicine, 18(1), 1-14.

Nedelkopoulou, N., Dhawan, A., Xinias, I., Gidaris, D., & Farmaki, E. (2020). Interleukin 10: the critical role of a pleiotropic cytokine in food allergy. Allergologia et immunopathologia.

Ono, S., Tsujimoto, H., Hiraki, S., & Aosasa, S. (2018). Mechanisms of sepsis-induced immunosuppression and immunological modification therapies for sepsis. Annals of gastroenterological surgery, 2(5), 351–358.

Prajitha, N., Athira, S. S., & Mohanan, P. V. (2018). Pyrogens, a polypeptide produces fever by metabolic changes in hypothalamus: mechanisms and detections. Immunology letters, 204, 38-46.

Stone, W. L., Basit, H., & Burns, B. (2020). Pathology, inflammation. StatPearls [Internet].

 

with the development of the disease as well as the process of immunosuppression and its effect on the body. The patient in this scenario developed the symptoms because of the possible side effects of the transplant procedure and the medications administered.

Symptoms Presented and the Pathophysiology

The patient developed symptoms because of the possible side effects of the transplant procedure and the medications administered.  According to evidence based research, Kidney transplantation has been proven to be the most effective therapeutic intervention medically in patients that have been diagnosed with chronic end-stage renal disease because it is the most desired and cost-effective method of renal replacement. The recipient’s immune response against the differing MHC surface antigens of the donor resulted in acute organ rejection. This often happens days to months after an organ transplant.  There is the possibility that the patient developed transplant rejection leading to renal failure that contributed to the weight gain and the reduced urine output (Kuan &  Schwartz, 2021). Furthermore, the sensitization of the body to the foreign organ contributed to the rising of temperate and feeling fatigued.

The Identification of Genes Associated with the Disease

The patients immune response to the procedure and medications is contingent upon certain factors such as  the genetic composition that can trigger symptoms like oliguria, incresed weight gain, fever and fatigue  (McCance & Huether, 2019). The specific genes that contributes to the development renal disease include rs25487 of the XRCC1. The gene makes people vulnerable to end-stage renal disease. Furthermore, the GSTP1 gene is also linked to the C-reactive protein and the ferritin levels. According to Abd EL-Hassib et al. (2021), individuals with the gene have increased risks for oxidative and carbonyl stress. Patients with end-stage renal disease have increased levels of C-reactive proteins which are indicators of increased inflammation. Furthermore, they demonstrate a high oxidative stress level.

Conclusion

Immunosuppression reduces the ability of the body to activate the immune response to the pathogens (Benvenuto et al., 2018). The process may be achieved through the reduction in the number of T-helper cells which recognizes the foreign objects and activate other immune cells to fight the pathogen (Tielemans et al., 2019). Alternatively, the effect may also be induced in the bone marrow. Besides, it reduces the inflammation in the body and the associated symptoms. However, it could be detrimental to the body because of the increased susceptibility to infections (Brown et al., 2017).

Finally, the human system is interconnected, and thus when one organ has been affected the rest may also suffer. In this case, the patient suffered organ transplant rejection and this could lead to increased inflammation. Decreased urine output was an indication of renal failure.

References

Abd EL-Hassib, D. M., Zidan, M. A., El Amawy, M. M., Hegazy, H. A., & Ameen, S. G. (2021). Polymorphism of XRCC1 Arg399Gln may predict for development of end-stage renal disease. A PCR confirmed case-control study. Meta Gene, 29, 100915. 

Benvenuto, L. J., Anderson, M. R., & Arcasoy, S. M. (2018). New frontiers in immunosuppression. Journal of Thoracic Disease, 10(5), 3141-3155. 

Brown, S. A., Tyrer, F. C., Clarke, A. L., Lloyd-Davies, L. H., Stein, A. G., Tarrant, C., Burton, J. O., & Smith, A. C. (2017). Symptom burden in patients with chronic kidney disease not requiring renal replacement therapy. Clinical Kidney Journal, 10(6), 788-796. 

Kuan, K., & Schwartz, D. (2021). Educational case: Kidney transplant rejection. Academic Pathology, 8, 237428952110068. 

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for

disease in adults and children (8th ed.).

Tielemans, M. M., Van Boekel, G. A., Van Gelder, T., Tjwa, E. T., & Hilbrands, L. B. (2019). Immunosuppressive drugs and the gastrointestinal tract in renal transplant patients. Transplantation Reviews, 33(2), 55-63. 

• Which Scenario to Answer in our Discussion Questions

  As you are aware, the class is divided into two groups and are each assigned a different scenario.  With that being said, when you respond to your peers – at least one of your responses needs to be to a peer from the other group.  If you just respond to peers from the same group then you are not learning anything about the other scenario.  So to be clear see below:

  Looking forward to our upcoming discussions,

  Dr. C

  Posted by: Kim Chapman

  Posted to: NURS-6501N-48,Advanced Pathophysiology.2020 Fall Quarter 08/31-11/22-PT27

• Cystic Fibrosis and Cholera

  Posted on: Saturday, September 12, 2020 9:31:31 PM EDT

  Cystic Fibrosis and Cholera

  I asked the question, What disorder/disease does Cystic Fibrosis help to protect a person against?  It is Cholera – and CF is a genetic disorder that developed to help with this other deadly disease.  Using the library, do a search and learn why this is . . .

  Dr. C

  Posted by: Kim Chapman

  Posted to: NURS-6501N-48,Advanced Pathophysiology.2020 Fall Quarter 08/31-11/22-PT27

• First Group Case Scenarios

  Posted on: Thursday, September 10, 2020 10:39:30 PM EDT

  First Group Case Scenarios

  Hello everyone,  as you answered a question about a salty baby or an overdosed adult there were two right answers.  The salty baby was Cystic Fibrosis and everyone with this assignment got it correct.  However, the second group was not as accurate.  The necrotic tissue on two separate locations was not rhabdomyolysis which was the prominent answer given.

  Rhabdo does occur in people who have been found laying on the floor/ground for extended periods of time and most of the time these individuals are older i.e. geriatric.  Young individuals with rhabdo usually have been doing heavy work/exercise i.e. marathons, weight lifting, bicycling in the heat etc.

  This person was found down as an overdose.  The two areas that were necrotic are often places where IV drug users inject themselves.  The necrotic tissue would not have occurred in an individual that was still alive i.e. the roommate didn’t know how long they had been down, but not long enough to sluff tissue.

  In the scenarios, you will be presented with, make sure that you are taking all the information given and putting the pieces of the puzzle together.  Some are more straight forward than others.

  Thanks for a great week of conversation!

  Dr. C

The Assignment (1- to 2-page case study analysis)

Discussion Week 1: Alterations in Cellular Processes

Week 1 Case Study:  A mother brings her 6-month-old daughter to the HCP for evaluation of possible colic. The mother says the baby has had many episodes of crying after eating and, despite having a good appetite, is not gaining weight. The mother says the baby’s belly “gets all swollen sometimes.” The mother says the baby tastes “salty” when the mother kisses the baby. Further work up reveals a diagnosis of cystic fibrosis. The mother relates that her 23-month-old son has had multiple episodes of “chest congestion” and was hospitalized once for pneumonia. The mother wants to know what cystic fibrosis is and she also wants to know if she should have any more children.

The role genetics plays in the disease.

Cystic Fibrosis (CF) is an autosomal recessive disease of the exocrine glands that affects several organ systems, the most important of which are the gastrointestinal and respiratory systems. CF is caused by a faulty CF gene on chromosome 7, one of the 23 pairs of chromosomes that children inherit from their parents. The cystic fibrosis transmembrane conductance regulator (CFTR) gene has a minor abnormality known as a mutation, which is a change in the DNA sequence caused by mistakes when the DNA is copied or by environmental factors such as UV light and cigarette smoke. This mutation causes the CFTR protein to express abnormally. Because CF is an autosomal recessive disease, an individual must be homozygous for the recessive allele to express the disease. In other words, everyone has two genes that express a trait. If both parents have one CF gene, they are both carriers, and when they have a child and each of them passes on the CF gene to their child, the child ends up with two CF genes and will have CF. So, when two heterozygous carriers of CF genes have a child, there is a 25% (1 in 4) chance that the child will have CF, a 50% (1 in 2) chance that the child will be a carrier and will not have CF, and a 25% (1 in 4) chance that the child will not be a carrier and will not have CF.

Why the patient is presenting with the specific symptoms described.

            The most common clinical manifestations of CF affect the respiratory and gastrointestinal systems. The 6-month-old baby cries after eating, has no weight gain despite a good appetite, tastes salty when kissed, and has abdominal distention, all of which indicate gastrointestinal symptoms related to CF. The thick, sticky secretion produced by the CFTR protein causes bowel movement to become stuck in the baby’s ileus, resulting in an obstruction and abdominal distention, causing the baby to cry after eating. Mucus buildup in the pancreas prevents the release of digestive enzymes that help the body absorb food and essential nutrients, resulting in malnutrition and poor growth in the baby. The CFTR protein balances fluid and salt in the cell; however, when the gene is mutated, CFTR functions poorly and salt is not transported correctly, explaining the salty taste in the baby’s skin.

The physiologic response to the stimulus presented in the scenario and why you think this response occurred.

The physiologic response seen in the scenario is a result of the mutation of the CFTR protein in the epithelial cells. This leads to mucus obstruction of pancreatic ducts, blocking pancreatic enzymes, and sticky mucus in the bronchioles, all contributing to the indigestion, constipation, chest congestion with obstruction of nasal airflow, and failure to thrive described in the scenario.

The cells that are involved in this process.

            The CFTR protein is an activated chloride channel found on the surface of many different types of epithelial cells, including those that line the airways, bile ducts, pancreas, sweat ducts, paranasal sinuses, and the vas deferens. CFTR regulates the flow of water and salt into and out of cells in the body, and changes cause mucus to thicken and stick together. This first affects the small airways in the lungs, but it can spread to all airways over time. The pancreas’ thick, sticky mucus prevents the release of digestive enzymes, which aid in the body’s absorption of food and essential nutrients.

How another characteristic (e.g., gender, genetics) would change your response.

            A person’s risk for CF may be increased due to family history and genetics, gender, and race or ethnicity. A person is more likely to develop cystic fibrosis if one or both parents is a carrier of a mutated CFTR gene or has the disease. A person is also more likely to develop CF if a sibling, half-sibling, or first cousin has the disease. Because CF is a non-sex-linked chromosome, it can affect both men and women equally. Caucasians have the highest carrier rate of CF, at 1 in 29. Hispanics (1 in 46), African Americans (1 in 65) and it is uncommon among Asian Americans (1 in 90).

References

Brown, S. D., White, R., & Tobin, P. (2017). Keep them breathing: Cystic fibrosis pathophysiology, diagnosis, and treatment. Journal of the American Academy of PAs, 30(5), 23-27. https:// doi:10.1097/01.JAA.0000515540.36581.92

Cystic Fibrosis Foundation. (n.d.). What is cystic fibrosis? https://www.cff.org/What-isCF/About-Cystic-Fibrosis/

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.