NSG 530 septic shock Essay Assignment

NSG 530 septic shock essay Assignment

Wilkes University

Passan School of Nursing

NSG 530

Case Study Power Point Assignment

Case Study Power Point Presentation

Based on your readings throughout the course, choose a disorder/disease from your text and develop a power point presentation. The NSG 530 septic shock essay Assignment presentation must include:

An introduction, incidence, prevalence (include to a global perspective), pathophysiology of the disease/disorder to the cellular level, existing prevention and therapeutic measures, current or future research relevant to the disorder/disease. The presentation must specifically address how this disorder/disease impacts ONE of the following age groups: infant/child, adult, or elderly. NSG 530 septic shock Essay Assignment

This presentation should be no more than 20 slides (excluding title and reference slide(s)). APA 7^th ed. is required. A minimum of 4 current (within 5-7 yrs) references excluding your text is required. Refer to the Grading Rubric for Written PowerPoint Presentations.

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Criteria

Topic Description: Introduction, incidence, prevalence (include to a global perspective), pathophysiology of the disease/disorder to the cellular level, existing prevention and therapeutic measures, current or future research relevant to the disorder/disease.

Application of disorder/disease: Specific to age group. NSG 530 septic shock essay Assignment

References: Use of 4 scientific references (excluding text). References must be current, within 5-7 years.

Other Criteria: Length not to exceed 20 slides (excluding title and reference slides). APA 7th ed. format required. Your PowerPoint should utilize graphics including but not limited to images, graphs, tables, etc. You may also audio record or voice over to provide an explanation of a slide.

PowerPoint Presentation: Septic Shock

Introduction

Shock refers to life threatening circulatory failure with inadequate perfusion to tissues

Clinically presents with hypotension and signs of hypoperfusion

Initially attributed to neurologic response to vasomotor circulation changes, and response to injury

Septic shock is a common non-cardiogenic cause of shock

Annually, septic shock occurs in more than 230,000 patients in the US

Results in more than 40,000 deaths annually

Seymour & Rosengar (2015) define septic shock as a life threatening condition characterized by circulatory failure due to inadequate perfusion of tissues. Patients will present with a mean arterial blood pressure of ≤65 mmHg or hypotension (SBP ≤90 mm Hg) with signs of hypoperfusion. Initially, researchers and clinicians attributed shock to vasomotor alterations to circulation and neurologic response to injury and categorized shock into hypovolemic, cardiogenic, vasogenic, and obstructive. In this presentation, the author discusses septic shock, a common cause of non-cardiogenic shock accounting for more than 230,000 cases and 40,000 septic shock-related deaths every year (Seymour & Rosengar, 2015). Currently existing evidence reveals that septic shock is the fifth leading cause of lost productive years as a result of premature mortality. Due to the public health burden of septic shock, in this presentation, the author reviews the global incidence, prevalence, pathophysiology, and management of septic shock.

Septic Shock

Source: Orme, H. (2016). Nursing a canine in septic shock: a patient care report. The Veterinary Nurse, 7(9), 542-547.

Incidence & Prevalence

Globally, there are 31.5 million and 19.4 million cases of sepsis and severe sepsis respectively (Hotchkiss et al., 2016).

Annually, there are more than 5 million sepsis-related deaths

Most cases are in low and middle income countries due to scarce knowledge about sepsis

There is no concrete data tracked in the Global Burden of Disease Report by the WHO on sepsis and septic shock

Areas experiencing high prevalence of infectious diseases such as HIV, streptococcus pneumoniae, non-typhoid salmonella should expect a high burden

Despite the high mortality associated with sepsis and septic shock, there lacks comprehensive epidemiological data on its global burden. The findings of the study by Hotchkiss et al. (2016) revealed that in well-developed nations across the globe, the cases of sepsis are approximately 31.5 million while those of severe spies are 19.4 million every year with more than 5 million deaths (Hotchkiss et al., 2016). However, the researchers highlight that these figures are only estimates since there lacks adequate knowledge on the mortality and incidence of sepsis in middle and low-income nations, due to challenges in generating population level data. In the US, findings from epidemiological studies indicate that in the year 2006, there were high incidence rates of nosocomial-related sepsis that ranges from 580/100,000 inhabitants in the US (Hotchkiss et al., 2016). These trends were similar in high-developed nations such as Australia, which had 194/100,000, and Germany whose incidence rate increased from 256/100,000 to 335/100,000 cases between 2007 and 2013 (Hotchkiss et al., 2016).

Incidence & Prevalence Cont’

The exact given incidence of sepsis in any nation is unknown

Reported incidences are highly dependent on the definitions used, the reporting mechanism, and infecting organism.

In most high-income countries, sepsis accounts for 2.8 million deaths annually

In the US, in 2005, severe sepsis incidences exceeded 750,000 equating to 2.26/100 discharges (Cecconi et al., 2018)

Generally, the incidence rate of sepsis is under-reported

The incidence will continue to increase with an increase in an ageing population

In the US, sepsis contributes to half of hospital-related deaths

The exact incidence of sepsis in each nation remains unknown and the current incidences provided by researches and scholars depend on the infecting organisms, the definitions used, and the mechanism of reporting. A lot of data describing the incidence of sepsis is from well-developed and high income nations whereby annually, there are more than 2.8 million sepsis related deaths. For instance, in the US, every year, more than 750,000 cases of severe sepsis occur. This equates to 2.26/100 discharge cases (Cecconi et al., 2018). In the United Kingdom, sepsis accounts for 27% of ICU admissions. The incidence of sepsis is generally under-reported. With the growth of an ageing population, researchers estimate that the incidence of sepsis will continuously increase. According to Cecconi et al. (2018), when compared to what’s reported, the exact incidence of sepsis and septic shock is higher. Evidence indicates that in the US, sepsis accounts for a third of all hospital deaths in the US. However, most deaths occur in middle and low resource settings where it is difficult to obtain population-based data. Current epidemiological studies estimate that 90% of global deaths from infections happen in middle and low resource settings. Of these infections, Cecconi et al. (2018) attribute 70% of 9 million deaths to chest infections among infants and neonates particularly in Africa and Asia.

Pathophysiology of Septic Shock

Source: Misra, D., Avula, V., Wolk, D. M., Farag, H. A., Li, J., Mehta, Y. B., … & Abedi, V. (2021). Early detection of septic shock onset using interpretable machine learners. Journal of Clinical Medicine, 10(2), 301.

Pathophysiology: Etiology’

Generally, sepsis may result from infection with fungi, bacteria, parasite, and viruses

It can also develop from non-infectious intraabdominal causes such as UTIs, severe abdominal trauma, pancreatitis, and pneumonia.

The most commonly identified infecting organisms are Escherichia coli (16%), Staphylococcus Aureus (20%), and Pseudomonas (20%) (Font, Thyagarajan & Khanna, 2020).

Predominant sites of infection are the bloodstream, respiratory system, and the genitourinary tract

Before the use of antibiotics in the 1950s, gram positive bacteria such as Staphylococcus aureus and Streptococcus pyogenes were the most frequent causes of sepsis

Gram negative causes became more frequent with drug resistance over time

Sepsis can originate from infectious and non-infectious sources. Infectious causes may include parasites, fungi, bacteria, or viruses. Non-infectious causes include severe trauma to the abdomen, pancreatitis, UTI, and pneumonia. The most common infection sites that cause sepsis are the bloodstream (15%), lungs (64%), genitourinary tract(14%), abdomen (20%), and renal (Cecconi et al., 2018). Infections with gram-positive bacteria are more common in comparison to infection with gram-negative causes. The well-known gram-positive causes of sepsis are Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa.

Pathophysiology: Etiology

Multidrug-resistant strains such as MRSA and vancomycin resistant enterococci (VRE) causing sepsis syndromes are on the rise

Risk factors predisposing to sepsis are:

¡malignancy

¡diabetes

¡major surgery

¡trauma

¡chronic liver and kidney diseases

¡corticosteroid use

¡prolonged admission into hospital

¡extreme age

¡presence of an indwelling catheter

¡hemodialysis

With the occurrence of drug-resistance to antibiotics, there are also sepsis syndromes caused by bacterial strains of multidrug-resistance such as MRSA and VRE (Cecconi et al., 2018) which are more severe. The risk factors that predispose to sepsis are trauma, hemodialysis, diabetes, malignancy, immunosuppression, extreme of age, prolonged admission to hospital, presence of an indwelling catheter, corticosteroid use, major surgery, and burns.

Pathophysiology

Starts with a systemic inflammatory response (SIRS) and ends with multiorgan dysfunction syndrome (MODS)

Starts with initiation of a host response to a pathogen which activates immune cells (natural killer cells, macrophages, neutrophils, and monocytes)

The proinflammatory cytokines activate leukocytes, the complement system, production of tissue factor, and induce acute phase reactants of the hepatic system

Hemostatic dysregulation which can result in mild thrombocytopenia or fulminant DIC (Disseminated Intravascular Coagulation)

The pathophysiology of septic shock often begins with the initiation of a host immune response to a pathogen resulting in the activation of innate immune cells. These cells include natural killer cells, macrophages, neutrophils, and monocytes. This happens through pathogen-associated molecular patterns commonly known as PAMPs that bind to cells of specific recognition receptors. Binding will activate intracellular signal transduction pathways, which cause the release of inflammatory cytokines (IL-1, TNFα, and IL-6) (Gyawali, Ramakrishna & Dhamoon, 2019). The Cytokines influence the proliferation and proliferation of leukocytes, the upregulation of molecules that adhere to the endothelium, activate the complement system, and promote the expression of cytokines and production of tissue factor. There occurs an intersection between the hemostatic and inflammatory paths when both get activated simultaneously (Huang et al., 2020). The outcome of this intersection may be mild thrombocytopenia, or disseminated intravascular coagulopathy (DIC). Dysregulation may result from the production of tissue factor by endothelial cells, which activates the coagulation cascade and results in a hypercoagulable state.

Pathophysiology Cont’

Immunosuppression leads to a decrease in the number of T cells due to apoptosis hence a decreased response to inflammatory cytokines

The immune system cannot stage an effective immunological response to infection

Early lymphopenia can be used as an immunosuppression biomarker for sepsis

Tissue, cellular, and organ dysfunction occurs with decreased utilization of oxygen by cells due to hypoperfusion

A prolonged immunosuppressive state follows the initial inflammatory state resulting in a decrease in the overall number of T cells due to apoptosis and a decreased immunological response to inflammatory cytokines. It also includes a decreased count of both CD4+ and CD8+ T cells (Gyawali, Ramakrishna & Dhamoon, 2019). During this phase, the immune system cannot respond to the infection. As such, clinicians can use early lymphopenia as a biomarker to detect immunosuppression among patients with sepsis. These cascades of events result in hypoperfusion due to a decrease in oxygen utilization and delivery by cells. Hypoperfusion has also been associated with increased circulating cytokines (IL- 1β and TNFα) which can cause myocytes of the cardiac muscle to be depressed as well as interfere with their mitochondrial function (Huang et al., 2020).

Septic Shock: Clinical Features

Source: Font, M. D., Thyagarajan, B., & Khanna, A. K. (2020). Sepsis and Septic Shock–Basics of diagnosis, pathophysiology and clinical decision making. Medical Clinics, 104(4), 573-585.

Evaluation

Initial inflammatory signs are evidenced by:

¡Tachypnea(a RR exceeding 20 breaths per minute)

¡Tachycardia( HR exceeding 90 beats per minute)

¡Fever (hypothermia or temperatures exceeding 380c)

¡Leukocytosis (WBC exceeding 12,000/cu mm

NSG 530 septic shock essay Assignment

¡Leukopenia with WBC less than 4,000/cu mm)

Cyanosis

Anuria/oliguria

Altered mental status

Hypoxia

Patients who are progressing towards septic shock will demonstrate signs and symptoms of severe or very severe sepsis and hypotension. In the initial stages, the patient may have maintained blood pressure, vital signs, and other signs of distributive shock such as a bounding pulse, flashed capillary refill, and warm extremities. At this point, if managed well through vasoactive support and fluids, clinicians can reverse the shock. As shock progresses to the uncompensated stage, hypotension sets in and patients may exhibit delayed capillary refill, cool extremities, and a thready pulse (Seymour & Rosengart, 2015). As hypoperfusion progresses, the patient progressively goes into multiorgan dysfunction syndrome (MODS) and even death. NSG 530 septic shock Essay Assignment

Evaluation Cont’

Complete Blood Count (CBC)

¡Thrombocytopenia (platelets less than 100,000/mL)

¡Leukocytosis (WBC more than 12,000/mm3)

¡Leukopenia (WBC less than 4000/mm3)

C-reactive protein

¡more than 2 SD above normal

Renal Function Test

¡Pre-renal azotemia

Coagulation profile

¡INR more than 1.5 or PTT more than 60 sec

Liver Function Test (LFT)

¡Hyperbilirubinemia (total bilirubin more than 4 mg/dL)

Arterial Blood Gas analysis

¡Lactic acidosis (more than 2 mmol/L)

Blood glucose

Clinicians should place patients with septic shock on a cardiopulmonary monitor to observe their vital signs. The nurse should also thoroughly assess patients for dysfunction of end organs and peripheral perfusion. This includes evaluating the MSE of a patient using the GCS (Glasgow coma scale) measuring urine output and determining the saturation of lactate levels. A C – reactive protein tests would help to differentiate bacterial sepsis from viral sepsis (Seymour & Rosengart, 2015). Before the initiation of antibiotics, the nurse must withdraw two blood culture sets NSG 530 septic shock essay Assignment.

¡Hyperglycemia (glucose more than 120 mg/dL)

Existing Therapeutic Measures

Source: Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., … & Dellinger, R. P. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377.

Existing Therapeutic Measures

Management based on the Surviving Sepsis Campaign Guideline

Controlling the source

¡administration of empiric antibiotics

¡remove necrotic/infected tissue

Managing shock

¡initiated within the first 6 hours

¡restore vital signs

¡fluid resuscitation

¡mechanical ventilation

¡administration of vasoactive agents

Enhancing the host response

¡administer corticosteroids

¡administer vasopressin

The management of septic shock starts with the administration of broad-spectrum antibiotics, which the clinician must administer within the 1st hour of diagnosis. Broad-spectrum antibiotics act on all pathogens and adequately penetrate tissues. If there are any infective or necrotic tissues as the primary source of the shock, the nurse should organize for its removal (Hotchkiss et al., 2016) NSG 530 septic shock essay Assignment. This includes abscesses, cellulitis, and infected wounds. To enhance the response of the host, the nurse should consider administering corticosteroids. This particularly applies to patients with low basal levels of cortisol (<150 ug/L) (Gyawali, Ramakrishna & Dhamoon, 2019). In vasoactive-refractory shock, the nurse can also administer vasopressin.

Existing Therapeutic Measures: Shock Management

Effective when implemented in the initial six hours of diagnosis

CVP (Central venous pressure) restored to 8 mmHg to 12 mmHg

MAP (Mean arterial pressure) restored to greater than 65 mmHg

Superior vena cava saturation restored to 70%

Administer crystalloids (NS or albumin) and colloids (blood products) for fluid resuscitation

Place the patient on mechanical ventilation to decrease metabolic demand

Administer first-line vasoactive agents such as epinephrine (cold shock) and norepinephrine (warm shock)

Existing Prevention Measures Cont’

Source: Centers for Disease Control and Prevention (CDC). (n.d.). Sepsis. https://www.cdc.gov/sepsis/prevention/index.html

Current/Future Research Relevant To Septic Shock

Rowe, T., Araujo, K. L., Van Ness, P. H., Pisani, M. A., & Juthani-Mehta, M. (2016, January). Outcomes of older adults with sepsis at admission to an intensive care unit. In Open Forum Infectious Diseases (Vol. 3, No. 1). Oxford University Press.

Impact to the Elderly

Sepsis is a potential cause of mortality and morbidity among older adults

Older adults in the US have high sepsis rates when compared with younger adults

When compared with younger adults, older adults are more likely to die from sepsis

Compared to age, factors such as functional status and comorbidities impact long-term outcomes

Impact to the Elderly

Older adults are at a higher risk of contracting pathogens that cause infections due to

¡Age-related changes on all body systems

÷Immunosenescence

÷challenges with pharmacokinetics and pharmacodynamics

¡Declining immune system

÷comorbid conditions

These vulnerabilities predispose them to higher risks of sepsis and subsequently septic shock

Sepsis has high diagnostic challenges NSG 530 septic shock essay Assignment

¡present with typical non-specific symptoms

¡Increased incidence of delirium and underlying multiple comorbid conditions makes it difficult to acquire a thorough HPI

Conclusion

Sepsis remains a common condition associated with a high mortality

Patients who survive sepsis have a long-term morbidity

There is a better understanding of sepsis and septic shock hence improved evidence-based management approaches

Current RCTs can help to increase nurses’ understanding of sepsis and septic shock

References

Bakker, J., Kattan, E., Annane, D., Castro, R., Cecconi, M., De Backer, D., … & Hernandez, G. (2021). Current practice and evolving concepts in septic shock resuscitation. Intensive care medicine, 1-16.

Cecconi, M., Evans, L., Levy, M., & Rhodes, A. (2018). Sepsis and septic shock. The Lancet, 392(10141), 75-87.

Clifford, K. M., Dy-Boarman, E. A., Haase, K. K., Maxvill, K., Pass, S. E., & Alvarez, C. A. (2016). Challenges with Diagnosing and Managing Sepsis in Older Adults. Expert review of anti-infective therapy, 14(2), 231–241. https://doi.org/10.1586/14787210.2016.1135052

Font, M. D., Thyagarajan, B., & Khanna, A. K. (2020). Sepsis and Septic Shock–Basics of diagnosis, pathophysiology and clinical decision making. Medical Clinics, 104(4), 573-585. NSG 530 septic shock Essay Assignment

Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE open medicine, 7, 2050312119835043.

Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews. Disease primers, 2, 16045. https://doi.org/10.1038/nrdp.2016.45

Huang, Y., Yang, J., Xie, J., Liu, L., Liu, S., Guo, F., & Yang, Y. (2020). Association between pathophysiology and volume of distribution among patients with sepsis or septic shock treated with imipenem: A prospective cohort study. The Journal of Infectious Diseases, 221(Supplement_2), S272-S278.

References

Misra, D., Avula, V., Wolk, D. M., Farag, H. A., Li, J., Mehta, Y. B., … & Abedi, V. (2021). Early detection of septic shock onset using interpretable machine learners. Journal of Clinical Medicine, 10(2), 301.

Orme, H. (2016). Nursing a canine in septic shock: a patient care report. The Veterinary Nurse, 7(9), 542-547.

Rhee, C., & Klompas, M. (2020). Sepsis trends: increasing incidence and decreasing mortality, or changing denominator?. Journal of Thoracic Disease, 12(Suppl 1), S89.

Seymour, C. W., & Rosengart, M. R. (2015). Septic Shock: Advances in Diagnosis and Treatment. JAMA, 314(7), 708–717. https://doi.org/10.1001/jama.2015.7885

Centers for Disease Control and Prevention (CDC). (n.d.). Sepsis. https://www.cdc.gov/sepsis/prevention/index.html

Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., & Dellinger, R. P. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377 NSG 530 septic shock essay Assignment.

NSG 530 septic shock Essay Assignment