Septic Shock: Initial Stage and Assessment (Nursing)

00:00 Okay, now let's move on to the next category.

00:04 Now, we're talking about the NCSBN Clinical Judgement Measurement Model, like, Whoa, how do we get here? Let me thinking like, "Why are we talking about this now?" Well, this is how you should be making decisions as a nurse.

00:21 So the Clinical Judgment Measurement Model, this means how you think like a safe bedside advocate who's practicing nursing.

00:33 So, this is going to be a model, we've got Layer 0, Level 1, those are things that go into clinical judgment.

00:39 Level 2, you get to form a hypothesis how these things work.

00:42 But this is where I want you to focus.

00:45 Level 3 is where you're going to be tested.

00:48 The Layer 4 is the next one.

00:50 They're talking about individual, and individual factors, environmental, I'm not so worried about that.

00:55 In fact, one, two and four can mostly be held up for your faculty to kind of guide you through that.

01:01 But Layer 3, that's where you should focus and really look at how to study things, particularly in your Med-Surg, and those types of classes on how you can interact with your patient and keep them safe.

01:15 Okay, now that we've gone all the way through that model.

01:19 And I took the time to explain that to you, because that will help you learn how to study better.

01:24 And I know that when I'm with my nursing students, they struggle with how to study.

01:29 They feel like they got to nursing school and really haven't been taught how to study.

01:34 So let's break this down now.

01:35 We're gonna talk about the stages of -- so you have first the initial stage.

01:40 Well, that's a clever name, isn't it? Then you've got the compensatory stage, then you've got the progressive stage, and then you have that final stage, the refractory stage.

01:49 We don't want anyone to make it to the refractory stage.

01:52 We want to try to resolve it. But here's what you need to know.

01:56 We're talking to you about the stages because the "cues", right, you're looking to recognize cues.

02:01 The cues in shock will vary depending on which stage you're in, in shock.

02:05 So, which one of these four stages the patient is going to be showing you different cues.

02:10 Now, I always talk to you about trends.

02:12 It's always good to know where a patient is coming from.

02:14 You may not get to take care of his patient till they're in the progressive stage.

02:18 And you can look back and see how they move through the initial stage, compensatory stage, and into the progressive stage.

02:24 So, understanding that sepsis is a full continuum, from sepsis, to severe, to septic shock.

02:33 So, let's zero in on the initial stage, right? So, we know the bacteria is in there.

02:38 You see that red band behind me that represents that, that's us, like in the bloodstream.

02:44 You see the other normal blood cells that are in your bloodstream and bacteria to remind us, that's what's happening.

02:51 Now, we're trying to attack it and take response.

02:53 But remember, this is a disregulated response to infection.

02:58 So, things are out of control.

03:00 They're extreme, they're over the top, which leads us into sepsis.

03:04 Now, we got all kinds of things going on.

03:07 Look what's happening, this reaction in the bloodstream? What kind of damage does this cause? Well, look at what's going on, did you seal that? Everything explode like that? That's going to cause damage to your intravascular space.

03:23 Now, the purpose of your intravascular spaces, that means your blood vessels, right, your arteries and veins is to keep blood on the inside, and then only allow fluid out that's appropriate and only that fluid in, that's also appropriate.

03:36 So, the walls of those vessels are meant to be very particular about how much fluid stays in the bloodstream and how much stays out. It's really cool system.

03:46 However, when a patient is septic, and we've gone through this type of experience, now these vessels become leaky.

03:53 Now, that's a problem, because in order to sustain a blood pressure that can deliver oxygen to my brain, my heart, my lungs, and the whole rest of my body, I need to have an appropriate volume in my intravascular space.

04:09 Now, the red blood cells are the thing that you see when you're brought into a lab too, but you've also got plasma and fluids in there.

04:15 And if things are leaking out, this is going to wreak havoc on the body.

04:20 I had a patient once, who had pancreatitis, and he was in septic shock.

04:25 We could not maintain blood pressure, no matter what vasopressors we use, no matter which volume we put into them.

04:30 And every bit of IV fluid we put into them, was leaking into the tissues.

04:36 So what the client looked like when they were admitted, from when they passed was radically different.

04:43 When I did post mortem care, and I took her old pair of shorts out of the drawer, she was like a size two, but who was laying in the bed was a body that was so overloaded with fluids, that even her tongue couldn't stay inside her mouth.

04:57 So, this is a really traumatic thing, because we can't fix it.

05:02 We can't go in there and plug up all those holes, we can't maintain their blood pressure, because we can't keep fluid where it needs to be.

05:08 On top of that these vessels vasodilate, they get bigger.

05:14 When your vessels vasodilate, your blood pressure drops, Because remember what blood pressure is? Blood pressure is all a fluid, the force that they're pushing on the walls of the vessels.

05:25 Well, if it's a bigger space, your blood pressure is going to go down.

05:29 Now, that's a concept nursing students really struggle with sometimes in pathophysiology.

05:34 The more fluid you have on board, the higher the blood pressure, because there's going to be more pressure pushing on those vessels.

05:41 But the less fluid you have, or the bigger the vessel, which is what happens in vasodilation.

05:46 That's why you're going to see their blood pressure drop.

05:49 So, you take this vasodilation and a vascular leak.

05:54 Okay, see it there? Now, we've actually showed you what the leak would look like, that's really just kind of a representation to get you thinking like, wow.

06:01 When a patient is going through sepsis, we know because of that extreme reaction to infection, the vessels vasodilate, the blood pressure drops, and fluid leaks out of that intravascular space, which will further cause our blood pressure to drop.

06:16 So you've got vascular leaking, and vascular volume depletion.

06:22 That's a big word. But what does it mean? Well, we've got less fluid in the intravascular space. Why? Because it's leaking out the walls, and the vessels themselves have dilated, The result of that is impaired tissue oxygenation.

06:35 Now why? And that's the way you study these things.

06:38 Don't just try to memorize lists, because it'll never stick with you.

06:41 But if you think about it, you picture this vessel.

06:43 You can even look at our vessel on the screen.

06:45 Look at that, I've got a vessel. Things are leaking out of it, It's much bigger. Blood pressure is lower.

06:51 Oh, that's going to be a lot less efficient in delivering oxygen to all my tissues.

06:58 So, that's why you have impaired tissue oxygenation in this particular form of shock.

07:04 Remember, you have impaired oxygenation in all forms of shock.

07:09 That's what it means.

07:10 But this one is caused by vascular leaking, and you've got the big vasodilation.

07:16 This is what's causing the loss of volume to be able to perfuse all those important organs.

07:23 This is what causes the organ damage.

07:25 We have less blood in the system to carry the oxygen around.

07:29 This is what causes tissue death, because the organs can't survive without oxygen.

07:34 So, because less blood is getting to the tissues, the cells in these tissues which were initially happy because they had all the oxygen they needed, start to struggle, as the lack of oxygen stops them from working efficiently.

07:48 This causes the cells to turn to other types of food that aren't as healthy as oxygen.

07:53 The problem was switching from an aerobic metabolism, a metabolism that uses oxygen to function to an anaerobic metabolism is that the anaerobic metabolism produces a lot of lactic acid.

08:05 And the problem with this is that although anaerobic metabolism does allow the cells to function, this only works for a short period of time because lactic acid is corrosive.

08:16 So eventually the buildup of lactic acid inside the cells leads to their death if the problem isn't resolved, and they continue to lack enough oxygen.

08:25 And on top of that, the liver cells are the ones that remove lactic acid from our bodies.

08:30 But to do this, they also need oxygen.

08:34 So, as you can see, the body is caught in a vicious cycle that keeps getting worse and worse if the oxygen supply does not increase.

08:43 Finally, only all of this is happening in a person with an active infection, which means that these patients will show signs of an infectious process such as fever and weakness.

08:53 With this, we have covered the initial stage of septic shock.

08:58 Now, we're going to move to the compensatory stage.

09:01 So, pause, for just a minute.

09:03 Write down the key points that you remember from the initial state of sepsis.