Week 8 - Septic Shock Flashcards
what is inflammation
part of the process by which the immune system defends the body from harmful agents
what are the 4 stages of the inflammatory response
- vascular response –> seals the injury via fibrin clots and mobilization of leukocytes
- cellular response –> sends help
- formation of exudate –> form circ to injruy
- healing –> regen and repair
describe the relationship between the inflammatory response and infection
- inflammation does not = infection
- infection = inflammation
describe how the inflammatory response changes w different agents
- it is the same regardless of the agent that causes cell injury
what is shock
- a syndrome characterized by decreased tissue perfsuion and impaired cellular metabolism
what is an infection
- an invasion of the body by a pathogen with resulting S*S
- can be local or systemic
- is usually bacterial
what is sepsis
- systemic inflammatory response to an overwhelming infection
what are some examples of things that can cause sepsis (3)
- uti
- wound
- indwelling lines
what is severe sepsis
- sepsis w organ dysfunction –> hypoperfusion and hypotension
what is imperative to survival w septic shock? why?
- early identification and intervention
- longer in shock & unstable = worse their condition gets = higher mortality
what is septic shock
- shock due to an overwhelming infection , causing hypotension that cannot be reserved by fluid resus and tissue perfusion abnormalities are present
what are the primary organisms that cause sepsis?
- gram + and gram - bacteria
what are risk factors for septic shock (12)
- very young pts
- very old pts
- immunosuppressed/immunocompromised pts
- malnourishment
- debilitated pts
- DM
- cancer
- CKD
- HIV
- HF
- invasive procedures
- indwelling devices
as a nurse, it is important to know ?? r/t septic shock (3)
- source of pathogen (ex. indwelling cath)
- causative agent (bacteria type, C&S)
- stages of shock
what is imp to know about the pt r/t septic shock (5)
- any diseases they may have (ex. liver disease)
- regular meds used
- age (v old or v young)
- baseline organ function
- any indewlling lines/tubes, wound/incisions (entry points)
describe the impact that liver disease has on septic shoxck
- causes the pt to move thru the stages of septic shock quicker –> lactic acid is produced during septic shock, which is usually broken down by the liver
why is it imp to know any regular meds the pts used r/t septic shock
- determine if any interactions between their reg meds and the rescue meds
what should you do if you suspect sepsis (3)
- act fast!
- if pt is high risk and are experiencing S&S, notify physician
- consider nursing protocol
what should be done while you are notifying the physician if you suspect sepsis (4)
- have a buddy ensure large bore IV access
- apply O2 (d/t increased CO that is seen at first = increased demand for O2)
- put pt in high fowlers
- take vitals
why is it imp to check nursing protocol is you suspect sepsis
- check if there is anything you can do or get started without a dr’s order
ex. blood cultures?
describe the clinical presentation of sepsis
- complex
- no single symptom or group of symptoms
what is usually initially experienced by pts in septic shock (3)
- hyperdynamic state
- increased CO
- decreased SVR
as the inflammatory response becomes overwhelmed in spetic shock, the result is.. (4)
- peripheral dilation
- increased cap permeability
- micro-emboli formation (decreased fibrinolysis)
- maldistribution of blood flow thru relative hypovolemia (d/t third spacing)
what are the general symptoms we will see in septic shock (stage dependent) (12)
- low BP (d/t vasodilation & fluid shift)
- increased HR and CO (in beginning)
- tachypnea (to try and compensate)
- crackles (d/t third spacing)
- changes to LOC
- decreased urine output
- GI dysfunction
- edema
- warm & flushed skin in early stages
- later, cold & clammy skin
- pain (chest pain d/t increased O2 demand)
- discomfort & anxiety
what GI signs may occur during septic shock (2)
- GI bleeding
- paralytic ileus
what is included in nursing care for septic shock (12)
- ensure airway is patent and assess ABCs
- optimize O2
- insert 2 large bore IVs –> fluid resus (need to reperfuse organs)
- vasopressors
- locate the source of infection
- send cultures
- abx therapy
- neurochecks q15 min
- VS
- monitor I&O –> foley cath
- assess perfusion (cap refill, peripheral pulses) q15 min
- stress ulcer prophylaxis(H2RB)
- DVT prophylaxis
how can we optimize O2 during treatment of septic shock (4)
- decrease demands (position changes, etc.)
- admin of O2 to keep at 90% or higher
- admin high flow O2 (100%) by non-breather mask
- anticipate need for intubation and mechanical ventilation
what is the cornerstone of therapy for septic shock
- volume expansion and restoration of perfusion w admin of the appropriate fluid
what type of fluids are used for fluid resus in septic shock (2)
isotonic fluids :
- NS
- LR
when should LR not be used for treatment of septic shock
- if pt has liver failure –> cannot convert lactate to bicarb
how can we monitor the pt’s response to fluid resus (2)
- BP
- insert indwelling cath to monitor I&O
what are 2 complications that can occur w the insertion of lrg amounts of fluids
- hypothermia
- coagulopathy
how can hypothermia during fluid resus be avoided
- warm the fluids
how cancoagulopathy be avoided during fluid resus
- replace clotting factors on the basis of the clinical situation and results of blood studies
at what point can vasopressors be used to help increase BP
- used if perfusion cannot be restored w fluid resus
- only after adequate fluid resus (if still low fluid vol, vasoconstriction would only worsen perfusion)
when should cultures be sent?
- before broad spectrum antibiotic therapy
what lab values should be monitored w septic shock (6)
- lactic acid lvl
- liver enzymes
- kidney function
- glucose (glycogen dumped into bloodstream)
- Na (increased)
- K (decreased)
what should be done within the 1st hour of septic shock and for at least 6 hrs (^6)
- give 100% oxygen
- take blood cultures to help determine abx therapy
- give IV abx
- give IV fluid therapy
- measure lactate and hemoglobin
- insert catheter, monitor UO
what are some ways to prevent septic shock (4)
- prevent infection
- decreased # of indwelling catheters
- use aseptic technique
- strict attention to handwashing
what should be assessed during acute intervention of septic shock (8)
- neuro status
- CVS status
- resp status
- renal status
- body temp & skin changes
- GI status
- personal hygeine
- emotional support
why is it imp to monitor neuro status w septic shock
- neuro status is the best indicator of cerebral blood flow
describe assessment of CVS during acute intervention of septic shock (4)
- assess BP and HR q15 min if unstable
- EKG monitoring continuously
- assess pt’s response to fluid and med admin q10-15 min
- assess perfusion
how often is resp status assessed during acute intervention of septic shock
- q15-30 min
describe resp assessment during acute intervention of septic shock (5)
- assess rate, depth, freq, and rhythmn of resps
- continuous pulse ox
- monitor ABGs
- many pts w shock are intubated & on mechanical ventilation
- maintain airway patency
describe assessment of renal status during acute intervention of septic shock (3)
- hourly measurements of urine output
- insert indwelling cath
- monitor BUN and creatinine
describe assessment of body temp & skin changes during acute intervention of septic shock (5)
- monitor temp
- keep pt comfortably warm w light covers and control of external enviro temp
- if has fever, use NSAIDs, tylenol, or remove covers as Tx
- monitor cap refill for perfusion
- monitor pts skin color & warmth
describe assessment of GI status during acute intervention of septic shock (4)
- auscultate BS q4hr
- assess for abdominal distension
- monitor for occult blood in stools
- monitor for signs of GI bleeds
describe mngmt of personal hygeine during acute intervention of septic shock (7)
- monitor for skin breakdown
- prevent infections
- oral care imp d/t dry and fragile mucous membranes r/t volume depletion
- consider priorities of care r/t bathing d/t increased demands for O2
- apply water-soluble lubricant to lips to prevent drying and cracking
- ROM 3-4x/day
- turn q2h
what are the stages of shock
- compensatory
- progressive
- refractory
what changes occur at the cellular level during shock
- metabolism changes from aerobic to anaerobic = lactic acid buildup
how is lactic acid removed from the body? how does this change w septic shock
- lactic acid = waste product
- must be removed by the liver
- however, no o2 to remove lactic acid d/t decreased perfusion
what is the compensatory stage of shock
- involves the body activating neural, hormonal, and biochemical compensatory mechanisms to attempt to overcome the anaerobic metabolism & maintain homeostasis
what signs are seen during the compensatory stage of shock (9)
- decreased BP
- decreased CO
- elevated HR
- body shunts blood to vital organs (heart and brain)
- skin warm and flushed (d/t hyperdynamic state)
- restless & confusion
- hyperdynamic state
- decreased GI motility
- tachypnea (to attempt to compensate)
describe the prognosis of the compensatory stage of shock
- may survive w aggressive treatment
what is the progressive stage of shcok
- stage that begins as the compensatory mechanisms fail and aggressive treatment is required to prevent MODS
what signs are present during the progressive stage of shock (16)
- edema (d/t increased cap permeability)
- tachypnea
- crackles
- increased WOB
- decreased BP and CO
- bradycardia
- changes in mental status
- weak peripheral pulses
- ischemia of distal extremities
- dysrhytmias
- myocardial ischemia, potentially MI
- renal tubular ischemia
- decreased urine output
- increased BUN and creatinine
- r/o GI ulcers & bleeding (d/t ischemia to the protective mucosal barrier)
- failure of liver to metabolize drugs and waste products
- cold, clammy skin
what symptoms does failure of the liver to metabolize during the progressive stage of shock cause (4)
- increased ammonia
- increased lactate
- jaundice
- elevated liver enzymes
what is the refractory stage of shock
- final stage
- everything is more profound
- decreased perfusion from peripheral vasoconstriction and decreased CO exacerbate anaerobic metabolism
- organs are in failure, body’s compensatory mechanisms are overwhelmed
what signs are seen during the refractory phase of shock (8)
- cold, clammy skin
- mottled skin
- profound hypotension
- bradycardia
- lactate increase = acidosis
- anuria
- profound hypoexmia
- failure of the liver, lungs, and kidneys = accumulation of waste products
describe the prognosis in the progressive and refractory stage of septic shock
- will likely not survive
what is SIRS
- systemic inflammatory response syndrome
- sysytemic inflammatory response to a variety of insults, such as infection, ischemia, infarction, and injury
what is SIRS characterized by: (6)
at least two of the following:
- fever
- edema
- hypotension
- tachycardia
- imapired oxygenation
- elevated WBC
describe the relationship between SIRS and septic shock
- can have SIRS not be septic
- or can be septic and have SIRS
what happens if organs are not perfused d/t the inflammatory response seen in sepsis or SIRS and it is not treated quickly?
- MODS
what is MODS (4)
- multiple organ dysfunction syndrome
- failure of 2 or more organ systems
- a progression from SIRS and septic shock
- high mortality rate
what is included in shock mngmt? (15)
- monitor VS
- monitor neuro status
- monitor UO
- monitor trends in hemodynamic paremeters
- admin crystalloid or colloid IV fluids
- monitor lab values
- monitor determinants of tissue O2 delivery (PaO2, SaO2, hgb)
- monitor for symptoms resp failure
- monitor fluid status
- monitor renal function
- admin O2 and/or mechanical ventilation
- monitor serum BG and treat abnormal lvls
- admin DVT and stress ulcer prophylaxis
- initiate early admin of antimicrobial agents
- admin vasopressors
what is included in shock mngmt r/t the CVS (4)
- monitor for inadequate coronary artery perfusion (EKG, cardiac enzymes, angina)
- promote adequate organ system perfusion (w fluid resus and/or vasopressors)
- promote afterload reduction (vasodilators, ACEI, aortic balloon pumping)
- promote optimal preload while minimizing afterload
what is included in shcok mngmt r/t vasogenic (6)
- monitor for physiological changes r/t loss of vascular tone (decreased BP, bradycardia, tachypnea)
- place pt in supine position w legs elevated to increased preload
- maintain 2 large bore IV access
- admin isotonic crystalloid as bolus doses –> keep systolic above 90
- admin abx
- admin sympathomimetic drugs
what is included in shock mngmt r/t volume (7)
- monitor for sudden loss of blood
- monitor for dehydration
- check secretions for frank or occult blood
- monitor for S&S of hypovolemic shock
- admin blood products
- monitor hgb and hct
- admin IV fluids
