Septic Shock: Developing Stages (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 Welcome back. Let's go into the second stage, the compensatory stage.

    00:06 So, we've gone through the initial stage.

    00:08 We know they've been infected. We know things have gone not well.

    00:11 Super response to that.

    00:13 We end up with leaking cells and low blood pressure and not being perfused well, switching to anaerobic metabolism, then you end up with a buildup of lactic acid.

    00:23 The liver can't deal with it.

    00:25 This is going to cause severe tissue damage.

    00:27 In the compensatory stage, look what's going on.

    00:30 So, we know that the metabolism has switched, right? We have the lactic acid buildup.

    00:34 We know that's a waste product in the body.

    00:38 Now, we have less stroke volume and less cardiac output.

    00:43 So, what are those words mean? Well, a decreased stroke volume means with every...

    00:50 with every stroke of the heart, there is less volume being pumped out of the heart.

    00:56 That's what a decreased stroke volume means.

    00:59 You also have a decreased cardiac output.

    01:03 Well, that makes sense, because cardiac output involves the amount that you're...

    01:07 pushing out with each beat.

    01:09 So, of course, you're going to have a lower cardiac output, because you have a lower stroke volume.

    01:14 This makes the hypoxemia worse.

    01:17 And look at that word, hypoxemia.

    01:20 Hypo, meaning low, and -emia in the blood.

    01:25 And in the middle, you've got -oxe.

    01:27 So, low oxygen in the blood, with the lower stroke volume, the lower cardiac output, you're going to have hypoxemia, low oxygen in the blood that becomes worse, even in this phase.

    01:40 So, this is really going to impact the cellular metabolism even further, right.

    01:45 So, things are not going well.

    01:47 Look at what our cells look like there.

    01:49 So, what can the body do? Compensatory, means I'm reacting. I'm trying to compensate.

    01:56 I'm trying to fix it in my body.

    01:58 So, if I don't have enough volume, right, what can I do? Well, tachypnea means, they're breathing faster.

    02:08 Tachy, -pnea meaning breath, right. So fast breathing, because they know, wow, I'm going to try to get more oxygen in as much as I can.

    02:18 So, that's what the body does, like, hey, crank up the rate of how fast you're breathing.

    02:22 Let's try and get more air in.

    02:24 So, tachypnea is the body's way to try to get more air into us.

    02:28 Tachycardia is fast heart.

    02:31 That's to compensate for that decreased stroke volume, decreased cardiac output.

    02:36 If we have less volume, we're just going to try and move it around faster.

    02:39 Are you getting the picture? You know how we ended up here in the compensatory phase because of what happened in the initial phase.

    02:46 Now, we're here with the body trying to fix it where breathe faster, pump your heart faster, see if that will deliver more oxygen to the cells.

    02:53 That's the goal. Because the body and brain know like, whoa, we are not getting what we need.

    02:59 Here's a cool flashback. You already know about baroreceptors.

    03:03 But take a look at this picture.

    03:04 We're showing you where they're located in the body.

    03:07 And these are the guys that activate the SNS, the Sympathetic Nervous System.

    03:13 I love they can reset themselves and all kinds of things.

    03:16 But I don't want to get lost on that bunny trail.

    03:18 Just know, this is where the baroreceptors are located.

    03:22 They pick up when the blood pressure is too low.

    03:24 The pressure is too low because we're in the compensatory phase of sepsis.

    03:28 And so they tell the body to vasoconstrict, right.

    03:32 They're wanting us to vasoconstrict the periphery.

    03:36 So we move it all the way back to the center of the body, where the brain and the heart are. So they're real selfish.

    03:44 They want the majority of the blood supply.

    03:46 So, if I am shutting down like this, if I'm vasoconstricting, what's not going to be well perfused? Fingers and toes.

    03:54 Everything is going to move from my periphery into the core of my body.

    03:59 Because remember, brain and heart are the ones who are super selfish, and they are always going to get what they need, right up until the last minute.

    04:08 Hypotension is the reason the baroreceptors are responding.

    04:12 They're kicking in that sympathetic nervous system.

    04:15 Now, you know what normal is because that's 120/80.

    04:18 You probably knew that before you came to nursing school.

    04:20 But look at the systolic changes in the MAP.

    04:24 So your mean arterial pressure and your systolic blood pressure when the heart is compressing, those are going to be lower.

    04:32 Remember, less blood equals less blood pressure.

    04:37 Now, there are some outliers.

    04:38 You can be someone who has uncontrolled hypertension.

    04:42 They may be a little higher than normal.

    04:44 But remember, that's an outlier.

    04:46 Most people will have hypotension, or low blood pressure.

    04:51 So, when that happens, we talked about the body shunting all the blood, that is why you'll have these pale hands or your tips of your fingers.

    04:58 And toes might look even kind of a bluish color, because they're not being perfused.

    05:03 So, you've got this SNS, right, the sympathetic nervous system, that stimulated the heart rate goes up.

    05:10 Increased heart rate and trying to pump as hard as it can.

    05:14 You've got an increased respiratory rate.

    05:17 That's what's going on. So you have the body trying to compensate for what the problem is.

    05:22 You want to have that increased contractility, because you want to deliver much more oxygen to the body in order to meet your needs.

    05:29 So, in general, you know that the sympathetic nervous system speeds things up.

    05:34 So, you know that the compensatory phase, it's going to speed up the heart rate, and how hard it beats, and the respiratory rate to try to compensate, all with the impact of trying to increase the amount of oxygen that's in the body.

    05:48 So, this is what the lungs look like with normal oxygen, right? But notice that those little oxygens are all the way through the lungs, top to bottom, left to right.

    05:57 That's what we're looking for in normal.

    06:00 But something really strange happens when you've got all this chaos going on.

    06:07 Now, gas exchange in the upper parts aren't possible, because you have decreased blood flow to the lungs.

    06:14 So, this is what ends up being problematic for the patients.

    06:19 You end up with physiologic deadspace.

    06:22 Now we've shown you where that is at the top kind of looks like that bluish color.

    06:26 That's the physiological deadspace.

    06:29 So, after you have the blood flow redistribution, this is what you end up in the lungs.

    06:34 So some areas of the lungs are being ventilated, but they won't be perfused. So what does that mean? You're going to be able to take air in, right.

    06:43 They take air in, but because they're not being perfused, there's nothing to carry that oxygen.

    06:49 So that's why we call it physiological dead space.

    06:52 Now, you don't have just this very small window of compensatory.

    06:55 It can be depending on the patient's status.

    06:58 So you understanding the cues that you should be looking for when you're caring for this patient will help you know where they are on the continuum.

    07:07 Now, this is the RAAS. You've seen this before.

    07:10 We've talked about it in all different kinds of settings.

    07:13 And I'm sure you've talked about it in pharmacology and medications.

    07:16 But this is just a quick overview of it.

    07:19 When the kidneys sense, right? Well, we're not being perfused. It releases renin.

    07:24 And it sets off this whole chain of events that end up with a body hanging on to more sodium, and being potently vasoconstricted.

    07:35 So this is another part that ends up with causing vasoconstriction all over the body.

    07:40 Now, I know we've got a lot of things all in there and how things go together. That's just how the RAAS works.

    07:45 All of this is going on at the same time.

    07:49 So, we're at initial stage we went through, that's the insult and exposure to the infection, major response.

    07:56 Compensatory stage, wow, the body tries to compensate and respond sympathetic nervous system overdrive, heart beating faster, lungs trying to breathe faster, blood being redistributed.

    08:09 We've got all kinds of challenges going on, trying to compensate and fix what's going on in the body.

    08:15 Third, progressive stage.

    08:18 Okay, so let's look at how this one is a little different.

    08:21 Patients in this one are going to be really anxious and confused Why? their brain is getting the message.

    08:26 If we keep going on this downward spiral, we are not going to survive this.

    08:31 So, the central nervous system is also less perfused than normal.

    08:37 But wait a minute.

    08:38 Didn't I say that blood gets shunted toward the brain into the heart? Yeah, it does. But it's still not enough.

    08:45 Okay, so that's why anytime a patient shows you anxious, confused. Always think about, are they being oxygenated enough? Is their brain being oxygenated enough? In this case, the answer is absolutely no.

    08:58 That's why we're in the progressive phase.

    09:00 Now, their hands might even feel cold and clammy. Why? Again, it's not getting the blood flow that it needs.

    09:07 Dysrhythmias and myocardial ischemia because the heart isn't getting enough blood that it needs.

    09:14 So initially, we had the problem.

    09:16 Then we tried to compensate, right, which means we increased our workload of everything.

    09:20 Now, it's like it's just tuckering out.

    09:23 It's tired. It's problematic.

    09:25 And so when the heart is limping, you're going to see things like this.

    09:29 And ischemia means lack of oxygen supply to the tissue that is right before becomes infarcted tissue.

    09:36 So these are the things that you're going to see in the progressive phase.

    09:42 Now, Swan-ganz catheter, this is pretty fancy stuff.

    09:45 This is only done in a critical care unit.

    09:48 But you can see that it's threaded through, right, the right atrium, into the right ventricle, over into that pulmonary artery.

    09:57 And that's why it's called a Swan-ganz or a pulmonary artery pressure.

    10:00 Now, we're not going to go into detail here.

    10:03 But we want you to know that this can do some really incredible fancy monitoring of the pressures inside the heart, and extrapolate what's going on in the rest of the body.

    10:13 But in this phase, this progressive phase, if someone has a swan-ganz, or a pulmonary artery catheter in, you would expect their wedge to be elevated.

    10:23 Okay, so that's what you expect in increased reg pressure, and we expect their central venous pressure to also be raised.

    10:31 Now, we've got the values for you on the screen.

    10:34 Your faculty may or may not go into this level.

    10:36 But you have it here, if you have the opportunity to observe a patient with a Swan, or to learn more about a Swan.

    10:43 So, the next step, this one is really severe.

    10:46 Acute respiratory distress syndrome.

    10:49 You're going to see tachypnea and crackles.

    10:51 And this patient is going to be in obvious respiratory distress.

    10:55 So you're going to listen for lung sounds, they're not going to be normal.

    10:58 The respiratory rates can be very fast, because they are just air hungry, trying to get it oxygen down to their cells.

    11:05 So, let's look at the rest of the body not as glamorous as the things we think about the brain and the heart, they're pretty fancy.

    11:11 But in this one, still, same thing.

    11:14 The problem was shock if you're not delivering oxygen to the rest of the body parts.

    11:19 Now, the gut is not the one that gets a lot of the blood supply, right? Heart and brain.

    11:24 So, you can't absorb nutrients like you need to This puts you in an increased risk for ulcers and GI bleeding, which is going to cause even less blood being available to the patient in the circulatory system.

    11:36 Now, don't be confused. Not everyone in sepsis develops GI bleeding, but it is one of those options that can happen.

    11:43 If they're in the progressive phase, their gut is definitely not getting enough oxygen.

    11:49 You can also end up with renal tubular ischemia.

    11:52 So, thinking like, "Whoa, this is a lot to remember." It's actually not. You're just looking at what happens to the tissues, when they don't get enough oxygen over a long enough period of time? Heart attack. Alright, kidney damage, gut damage, everything is going to be more sensitive and at risk when it doesn't get the oxygen it needs.

    12:16 So, when it's prolonged, this is how it progressed on the continuum unless we can turn it around.

    12:23 Ischemia, these tissues will eventually lead to infarct of these tissues.

    12:27 Then you've got even more challenges with bugs going where they shouldn't go, fluids being where they shouldn't be, organs not functioning, it is dysfunctional, dysregulated chaos in the body.

    12:39 Now, the last phase is the most serious.

    12:43 It's the refractory stage.

    12:45 Initial phase, whoa, we got infected with something.

    12:49 We had this major response to it.

    12:51 We got things leaking in vasodilating.

    12:54 Compensatory stage, whoa, the buddy says, "Hey, help me.

    12:57 I'm going to breathe faster. I'm going to pump harder.

    12:59 I'm going to move things around a lot more." Progressive stage, they're just wearing out, right? It's long enough and prolonged enough, the body systems are going to give out because they didn't get the oxygen they needed.

    13:12 Now, we're in the refractory stage.

    13:14 There's really no coming back from this.

    13:17 You'll see the signs neurologically where the patient have nonreactive pupils.

    13:21 They are unresponsive. You cannot get them to respond to you.

    13:26 Their hypotension gets worse and worse and worse.

    13:29 All the vasoactive drips you get are all the fluid you pump into them, it's not going to resolve the low blood pressure.

    13:36 They can also have severe hypothermia, like really severe hypothermia.

    13:42 You see the numbers up there on the screen.

    13:44 So this is a really poor sign of the progression of sepsis.

    13:52 So, keep in mind, you're thinking, what about the NCLEX? How could some this be used on the NCLEX? Well, in the beginning, the patient had a high fever, right? Because the body is trying to fight off that infection.

    14:05 But later on, it can't. It almost just like gives up.

    14:09 And that's all you have hypothermia at this really late stage of sepsis.

    14:15 Respiratory failure. We talked about we're just moving all the way down from top thinking about temperature.

    14:22 Your lungs are going to have respiratory failure.

    14:24 They're going to give out.

    14:26 You're going to have an ischemic gut and that is incredibly problematic for the body.

    14:32 And for it maintaining energy and delivering what the cells need.

    14:35 They're gonna have hypothermia, because it just can't control their body temperature anymore.

    14:40 This is not a sign of a good outcome, right? Cyanotic hands are going to be something that you see.

    14:47 It's not our biggest concern.

    14:49 But it also is just another sign that tells us, the body is so poorly oxygenated or perfused.

    14:56 That it's going to be very difficult, if impossible for a patient to survive.

    15:01 Their kidneys are going to shut down.

    15:02 They're going to stop putting out urine.

    15:04 It will become less, and less, and less.

    15:06 It'll become thicker and darker, and not that much of it.

    15:10 Because the kidneys are suffering the damage of ischemia from the lack of oxygen to her.

    About the Lecture

    The lecture Septic Shock: Developing Stages (Nursing) by Rhonda Lawes, PhD, RN is from the course Shock (Nursing).

    Included Quiz Questions

    1. Nonreactive pupils
    2. Severe hypothermia
    3. Cyanotic extremities
    4. Mild hypotension
    5. Polyuria
    1. Decreased nutrient absorption
    2. Cold extremities
    3. Renal tubular ischemia
    4. High fever
    5. Hypervolemia
    1. Areas of the lungs where gas exchange is not possible due to lack of perfusion
    2. Areas of the vital organs where baroreceptors have triggered widespread vasoconstriction
    3. Areas of fluid buildup in the lungs caused by hypervolemia
    4. Areas of fluid buildup in the pleural space leading to impaired tissue perfusion
    1. Blood pressure 85/50, heart rate 120, respiratory rate 24
    2. Blood pressure 82/58, heart rate 40, respiratory rate 10
    3. Blood pressure 140/90, heart rate 110, respiratory rate 18
    4. Blood pressure 100/74, heart rate 75, respiratory rate 16
    1. By shunting blood to the heart and brain via systemic vasoconstriction
    2. By shunting blood to the peripheries and vital organs via systemic vasoconstriction
    3. By attempting to increase perfusion to the entire body via systemic vasodilation
    4. By shunting blood to the liver and kidneys via systemic vasodilation
    1. Decreased stroke volume
    2. Decreased cardiac output
    3. Hypoxemia
    4. Bradypnea
    5. Bradycardia

    Author of lecture Septic Shock: Developing Stages (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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