again if you don't know normal you cannot discern abnormal okay so it's going to take some time for you to go back and review pull those concepts up use the multiple resources you have to do so okay module b you're going to have to go back to 105 abg's there will be abg's on the module b test and we will not discuss them in class we can't re-teach every course every semester you'd never get a nursing school with you okay but when you've successfully passed a class that attests to the fact you can bring that information forward am i responsible by the board of nursing for my health assessment in 1984 yes i sure am i had a successful grade and of course therefore i'm required to maintain competency in that area okay so we can't forget it and move on we got to keep building on it and go forward all right so let me do something really quickly here because i i love the visual part so something we're going to do to kind of help you get the basis for this i think helps okay i try to appeal to all my different kinds of learners you know who's my visual my auditory my kinesthetic my reader get all those different types of learning styles down pat here so we're going to take a little trick it'll be just a second then i'll pull this up oh five more seconds okay this is where we're at i know where this is at it's my favorite place in the united states it's about four hours away from my parents live it's jackson hall wyoming every time i go home see my parents we'll go here this is a beautiful beautiful mountain little bitty town and there's a river right behind here as you turn left here this goes to yellowstone there's this river called the snake river now i'm just gonna hide this for a second because i need you on the snake river not traveling right now i want you to envision the snake river okay it's this beautiful winding river that goes and leads towards the tetons and then jackson hole i mean the yellowstone everybody picnicking with me by the river okay there's there's geese there's ducks there's there's elk out in the distance it's beautiful serene is my happy place it's cool it's gorgeous okay so if there was a lot of snow in the mountains that winter how will that affect the volume in the river okay it's going to rise how will that affect the force of the flow it's going to increase it didn't it we all can see that right we see that river we see it's rising to the banks because the snow has run off it's melting and it's increasing the volume in the river therefore it's increasing the force of the current everybody there with me all right what if we were to take the sides of that river and expand the width of it what will that do well are we reducing volume but proportionately are we reducing volume yes how will that affect the force of the flow in that river the current it's going to slow it down substantially isn't it will it per say be adequately adequate enough now to go distal not necessarily right okay y'all that there's nothing different about human body than that if i have systemic vasodilation imagine every artery in your body is dilated doesn't that proportionately reduce volume and then will it not proportionately reduce the force of flow okay that is our basis for what we're going to talk about by jacksonville if i'm sad or lonely or homesick i'll pull this up on my phone just watch it but i don't know why i'll sit there with the audio on he was like here's the trucks and the cars go by i'm like my family and i take pictures of each other those little one of those little corners and moose antlers nerdy little things we tell each other hey get on the webcam we're going to be standing here we really do we really really do this okay so let's talk about the processes that lead to the systemic vasodilation okay if you were to with my son a long long time ago when he was taking down a big tree house he had built um and i got tired of looking at it because he wasn't playing anymore because he was older and i tear that thing down so he was he was breaking it down and as he was he stepped on a three inch rusted nail partially embedded into his heel through his shoe okay if i were to look at that heel nails out we're looking at the heel hemostasis takes place pretty quickly in a healthy individual right so we've got some clotting going on is that that's part of that inflammatory process what's going to happen to the site locally what's it going to look like okay why is it red what causes that the normal response okay but in what part of the normal response is causing the redness very specifically okay because of our histamine response we're going to have localized vasodilation localized which is why we've got an area of redness but it doesn't spread beyond that part which is good right why do we need that vasodilation to occur there what's going to happen if those vessels are larger what's it going to permit more volume to get there which with that volume comes hemoglobin comes the cells necessary for repair correct comes fluid plasma all of that is a good thing because it's going to help already start protecting and healing this injured area so that it's going to be red how's it going to feel to touch that redness and it's because those vessels are at the surface and they're dilated correct all right now there's going to be some serous fluid what's the purpose of the serous fluid protection protection right it's going to protect the injured tissue correct let's say a few days from now we see periodic drainage what was the consequence that created that purulent drainage uh-huh what's the process called pac-man way too young for pac-man i didn't like that i'm just going to tell you i'm not most people phagocytosis good job phagocytosis so it's the end product the waste product of our healthy cells destroying the bad cells and this is the waste product all of these things were normal and necessary and in a healthy individual will take place that keeps them from getting what really sick keeps that pathogen from going any further all these localized effects are supposed to be there the problem is if we have people who are predisposed who don't have a strong immune response that localized response may not be enough to prevent the pathogen from going where through the bloodstream and begin to travel once a pathogen is in the bloodstream where is it going to go wherever blood goes so now this response that's ideally perfect in a localized setting is catastrophic systematically system that systemically is the correct word you see where we're where we're at right now so we start thinking about you remember i was telling you guys i think on module a what sets you apart in your discipline as an online from every other discipline is your ability to quickly and in moments strategize with your patient what is your patient's highest priority but you have to understand what their risk for the only way you understand their risk force to have your education knowledge and training because if i can identify what my patient's at risk for i can proactively implement measures to prevent bad outcomes correct okay but that takes me understanding who's at risk who's at risk for this and remember that infection can be anything it can be a uti it can be pneumonia it can be anything but somehow a pathogen was able to successfully get through that bloodstream throughout the body now we have a problem on our hands even if i were a young person okay so let's go through the steps the processes here and think about what we what's going on with my patients so we have bacteremia we'll have blood positive in the in through blood cultures bacteria rather we had a primary infection that triggered that inflammatory response so we're going to go through all these different steps what is serious criteria etc etc so some things you're going to have to commit to memory like this normal testing level this is one of those things three t's and a w you have to know these values that have to be committed to you like your social security number don't add any values don't take away any values sears criteria are these four things three t's and one w so look at your temperature if your patient meets two or more of these criteria we have to put them on a sepsis pathway so look at your temperature you've got two variants here a less than and a greater than your heart rate now typically the standard definition for tachycardia is what greater than right but look what we have for our definition for tachycardia specific to sears criteria greater than okay we have a respiratory rate to kidney that's classic with our standard definition and then we have white cells a greater than or a less than value um janae was you were chloe yesterday they had a patient with a count of 3.5 it was you okay so you see where we're at here remember i was telling you i was concerned about septic shock for this patient because this is what we're going this is what we're talking about all right so if your patient has met two or more of these values we're going to put them on a sepsis pathway because what we're concerned about is uh oh has a pathogen successfully invaded the bloodstream and we're starting to see that systemic inflammatory response now will i sit back as a nurse and say ah that's a chronic copd patient they always breathe greater than 20 you know and and they're always tachycardic because a lot of the meds they're on so i'm not going to put them on a pathway is that safe or unsafe it's very unsafe you've just tried to diagnose number one which is beyond your scope of practice by the way does the board of nursing let you practice beyond just go to practice the answer is absolutely not the board of nursing is one of those entities you want to be on their approved provider list but you don't want their attention you got me it would be unsafe for me to assume that this is what's causing that no harm is going to come to my patient by me putting them on the pathway and say hey we need to rule this out but i can cause the patient's death by failure to do so because timing is everything right now we have got to get on board and get ahead of this packaging as fast as we can okay so you're going to commit this to absolute memory like a normal lab value like your social security number because again if you don't know what the normal criteria or there's no way you're going to be able to build on that or act on that and this goes back to my little soapbox thing about people who take vital signs you are responsible for the values that are being obtained regardless who got them so you know what you might want to make sure they're accurate i would okay i'm going to make sure that the values that people are obtaining on my patients are valid what kind of attempt do you think we need to use here is this an axillary temp no this should be a core temp at minimum okay and if you don't have the route access necessary to do a core oral would be my minimum safe standard all right so let's now some of these slides i'm going to click click click click because they're just reminders for you we have endogenous within we have exogenous without um sources of pathogens okay we know that which are the of the two are easier for us to control the endogenous or the exogenous sources that's right we can control the outside of the patient we can't control as long as other body or what predisposing risk factors they came to us with but i can control what i've done for my patient i can control what i'm bringing to the patient as far as my care my pathogens i'm bringing okay that's between those two you know 24 power over again we've got the very young the very old that y'all i hate saying that because over 65 oh it's not but you've got those two spectrums and again we know why the young have an immature system hasn't been exposed to a lot and our geriatric patients are like i hope to be soon retired okay so we've got these two spectrums all right and and with that adds inherent risks okay then we have people who are getting what kind of medications would predispose my patient to successful pathogen invasion immunosuppressive therapy such as chemo what else corticosteroids because what does steroids do they tell the inflammatory response to chill out nobody okay which in later phases is great but in early phases could have prevented this so if i've got a system that was already dampened by steroid therapy this patient's gonna be more susceptible to successful invasion okay what about the more lines and tubes don't we poke holes in places that never had hope before they all kind of holes don't they we put something in every orifice we could find does it matter my technique that and the methodology i use to do those things it does again i'm going to tell you once again you check yourself if you know you're doing something you wouldn't do on somebody you love you don't need to be doing it bottom line okay and i'm not going to lie to you tell you everybody's just all wonderful and nice to you they're not they're not but you are ethically morally bound to provide that care for them okay so we're going to do things right we're going to protect our patient we're not going to expose them to additional issues all right so you've got a little list of different things why would all the what what is it about this that predisposes my patient to pathogen innovation multiple portals of entry i'll remember from fundamentals portals of entry procedures so all these different things predispose my patient to risks what about malnutrition how does that play a role i'm not able to find out that's exactly right if you haven't had your wheaties you don't have the energy for or repair again moving right along so what does it look like well in the beginning you're going to start seeing the evidence of the riverbank being widened in response to the systemic inflammatory response so what value is going to go down when volume is proportionally reduced because the size of the space increased blood pressure isn't that the same mechanism action of a vasodilator isn't it doing the same thing is causing the stazo dilation so we're going to start seeing some hypotension and again this is where mean arterial pressure is important because what did we identify in module a as a necessary mean arterial pressure to sustain adequate organ perfusion 65 and above good job guys so here we're going to start focusing on that mean arterial pressure we're going to look at that oh here we have a narrowed pulse pressure what did we say in module a contributes to a narrow pulse pressure a reduction of watts now we start seeing elevated lactate levels what how does that happen what's going on at the level of the organs that would cause us to have rising lactate levels what do you think they're breaking they're breaking down this is true why what's causing that they're trying to work in an anaerobic environment if we don't have adequate blood flow to an organ thank goodness it does doesn't clock out it's like okay i'm going to continue to work for you just a little bit because i see this line of customers coming up but i really want to clock out because you hadn't paid me okay thank goodness they continue to try to work for us but unfortunately as they continue to try to work in an anaerobic environment why is it anaerobic because we have poor perfusion why do we have poor perfusion because we have systemic vasodilation we have a river that has lost its forceful flow okay the end product the waste product if you will from that anaerobic metabolism is lactate so we're going to start seeing rises in lactate level when you get a lactate of two or greater you start having some red flags when you got a four you've got a septic patient okay and then look at our renal function we start to have evidence of renal dysfunction again perfusion and then hepatic dysfunction remember in your livers where your clotting organizations are look what's starting to happen to our clotting values and our platelets like what's going on okay well that's a little complicated because there's another factor that goes along with that all of these areas at the organ level where we're having this anaerobic metabolism occur it will result in little injured areas again if we have our lactate being produced what does the body try to do when something's injured it tries to help repair it so here's where you're going to start seeing your fibrin being utilized fibrin's going to go to all these areas of endothelial damage and what does that do to our other stores it starts to deplete them it's a very complex cascade doesn't that further impede organ perfusion have all these little micro clots everywhere okay so you see how this is becoming a really nasty situation where when it was localized was great all agaria again related to your kidney dysfunction now and remember what i said your brain is super sensitive to perfusion and oxygenation understand when you assess something your orientation status assesses something completely different than your level of consciousness does that's why it's alert and oriented we're assessing two different parameters so you're going to start seeing that level of consciousness decline your patient's going to become more what we call somnolent you remember that word a little more drowsy a little more difficult to awaken okay like what's going on with that oxygenation can lead to confusion alter states of mental status there but can't we have a perfectly perfused brain but still be disoriented yeah because there's other organ or organic processes that can cause that that's why they're separated into two different things that you're assessing okay so altered level of consciousness we start having a patient that's becoming less and less responsive what are we gonna do we're going to open up the dam and fill up the river and y'all remember this is your priority action is to replace that volume we didn't lose it per se right even though there is some interstitial loss because when matthew injured his heel would you not expect to see swelling occur very quickly what caused the swelling guys pathophysiologically what causes the swelling okay fluid is now able through this inflammatory process to enter spaces it couldn't enter before we went from having a screen to a chicken wire molecules that were by nature and size not permitted prior to enter those spaces has are now given cell wall permeability in other words changes okay so that's what constitutes the swelling so we in systemically we will have a degree of fluid that extravasates into the tissues now which further compromises my perfusion doesn't it okay um what we're going to try to do very aggressively is fill that space we're gonna we gotta spill fill that space your ati book always always bring this with me y'all you you are not helping yourself if you don't read this chapter in ati okay now it kind of puts all the different types of shock together what what does that say chapter what 37 chapter 37 you need to read it and you're not helping yourself if you don't put all these different because it's going to talk about a lot of different types of shock but it kind of conceptualizes things for you and it also stresses the importance of if volume is what you don't have volume is what you replace i had a student a few semesters back and i this these are the things that just haunt me i'm like oh i wish you had not said that she was an ems person too going through nursing school but she said that she had a severe volume depleted patient who was also hemorrhaging and they kept telling her when they were calling in that she was treating the patient in route to continue to replace volume volume volume volume and she said i just you know that just seems crazy to me i put them on dopamine i'm like oh my god why did you tell me that i don't ever want to see you on my ambulance because it scares me that you have the audacity to think that you know more when you clearly don't know what you don't know or you wouldn't have told me that we've got why would the dopamine not help a patient like that there's nothing to increase you've got vessels that don't have adequate volume now what you're going to do with them you can only pinch them so much like what's going to happen now nothing is the answer but incre and you've instead caused a lot of other consequences physiologically that can have a bad outcome for your patient if volume is my problem volume is my fix remember i have a systemic pathogen right now it is running around my body the first and best most effective thing i can do is fill the river okay so what are your volume expanders what are the fluids you would expect to find lr and normal saline look at what our cvp has to be what was a normal cvp in module eight two to six good job why do you think i need an eight to twelve now that's right because we don't have normal vessels we have larger ones we need more to sustain that so your cbp 8-12 is what we're striving for okay so these are some of the things we would do to measure to see if we've gotten adequate volume on board okay would blood transfusion be the answer here no because we're not losing blood volume we need fluid volume if the patient doesn't respond to our fluid volume resuscitation which is at 30 mils per kilogram notice there's no time there it's 30 ml per kilogram you may have to free flow it get it in there okay your provider may say i want it over an hour most likely it will be a 30 mil per kilogram bowl let's get it in there let's get moving if they don't the vasopressor of choice is norepinephrine that is your vasopressor of choice you will see some providers use phenylephrine neocinafrin but it it even if you do some extensive research on that it's it's not indicated for the treatment of septic shock it can be used in other types of shock but septic shock responds best to norepinephrine okay but that's after so what are we doing here with norepinephrine okay we've tried to fill volume in the riverbed and now we're taking a backhoe and trying to close the bank back up is what we're trying to do because our goal is to get perfusion to those vital organs so jay what is your patient's extremities going to look like when we start that norepinephrine remember your patient oh the blue yellow the cool and blue cool model grayish blue depending on your patient's complexion you'll see a discoloration and they're cool because that's what it's doing is pulling from the periphery shunting to your core okay all right priority also early on get those blood cultures before you initiate an antibiotic why would i do blood cultures before i initiate an antibiotic that's right now i'm an army brat my daddy flew cobras so i love the arm i feel safe i love growing up on military institutions i love the sound of choppers and the tanks rolling by in the mornings and the soldiers i mean i grew up with that and i loved it when you're dealing with you send out your little scout helicopters your oh helicopters to observe and find what's going on out there to communicate back to home base what are we dealing with i need an accurate picture right i don't need one little random militant group to go take out part of it and destroy my sample size that i really don't know what i'm dealing with do i when you start an antibiotic before you've obtained blood cultures you're distorting the true picture we've got to know who we're dealing with what quantity are they how virulent are they you remember that term from fundamentals numbers how potent is this bad boy how are we dealing with this okay so my antibiotics will follow after blood culture has been obtained how do we obtain blood cultures how many sites do we use two why do we use two sites so that we know we have a legitimate outcome when i do one sample and maybe during my sampling i didn't exercise good caution i didn't clean the skin well enough and my sample comes back positive for staff and i assume that okay well they've got staff and it's erroneous because it was a sampling error if i've got two samples and one sample comes back positive and the other one's negative there's no way half the body is infected and half the body's not so there was a sampling error so we do two both should identify the exact same organism and we had two different sites okay that's how we make sure that what we're looking at is true and accurate your your method of obtaining blood cultures is really important guys that you use the proper technique especially if you're drawing the blood cultures from a line that you've swapped your ports carefully you've wasted your first draw you've used your second draw all these things and you'll see that this semester through the intensive care okay um oxygenation is going to be imperative because your patient most likely is going to have intubated because this systemic response leads to poor perfusion to the lungs we're going to see that same effect in the lungs that we saw in the tissues where fluid interspaces it wasn't able to enter before which is going to impede gas exchange isn't it and these patients become profoundly hypoxic and require intubation chloe i think that was your patient we had on 95 fio2 right with the drake no not yours was it yours janae you remember what i'm talking about now okay 95 fio2 you can't go much higher than that i mean we run out of options when you've got a septic patient like that they come very hypoxic okay so we've got fluid filling in the lungs impedes gas exchange and now we have a hypoxic patient we're going to go ahead and start our vte prophylaxis because we know people who are mechanically ventilated or people under any physiological stress or predisposed to increase hydrogen ion production which will increase gastric ulcer development and then cause them to bleed okay we can't have any of that going on um glucose control tight tight glucose control what does your body do during physiological stress to your glucose levels does it increase it or decrease it increases it why because it's trying to meet an energy demand right i mean i need my i've never drank i don't i'd be scared to drink red bull but it's red bull for your body okay it's like listen we need some energy i need some sources here i got to work but we we found that patients have much poorer outcomes when we don't maintain tight glucose control so we're going to be really stringent with this we may have to put them on insulin drip if necessary but they're going to be we're going to keep those blood glucose levels below 180 and i didn't notice i did not say diabetic this is anybody okay tight tight glucose control so we're going to be really busy with this patient don't uh let's just read that that's interesting moving on let's talk about the phases of shock so we started with what we started with a pathogen somewhere it was in the lungs it was in the bladder it was from a central line that was inserted and then not cleaned under using sterile technique whatever okay a pathogen was successful entering the bloodstream because of all the different factors we identified earlier the patient became bacteremic they start exhibiting serious criteria we put them on a substance pathway oops indeed they are septic we have pathogens identified in the bloodstream now we start seeing that severe sepsis we start seeing that early hypotension changes in llc lab values start to change all as a consequence of poor organ perfusion and then we proceed into the stages of shock in the now this stage of shock has different names it might be called compensatory hyperdynamic warm you name it they all mean the same thing this is the body's hoorah session it's like okay i'm gonna fight one more time i'm gonna try really really hard to overcome this and that's what you're seeing physiologically so you're gonna see the the patient will look warm to like you look at me like i bit when i touch them they're warm they've got that rosy flushed appearance you know touching them indeed they are because what i'm having here is that massive catacombing surge is making the heart contract much more forcefully right now so it's having a positive ionotropic effect on the cardiac muscle those kind of colonies are it's like muscle you got to do something because it's not a problem houston so through that catecholamine surge and that increased contractility you're going to see cardiac output either normalize or rise and you're going to see blood pressure either normalize or rise because it is compensatory this is a phase that's like i'm going to try really really hard to overcome this and that's what's happening right now however behind the scenes we're really not accomplishing a whole heck of a lot because if you look your patient's loc continues to decline renal function continues to decline hepatic function continues to decline glucose levels continue to rise my gas exchange continues to become compromised what is a hallmark of this phase of shock it's that normal or increased cardiac output that is specific to this phase and no other but when i look at all the other things that are going on with my patient bounding pulse why we have a reduction of sbr okay and constantly an increased cardiac output now that reduction of svr is not a good thing right now folks because we need the volume to be able to come back to this to the core if i have very little resistance systemically what's going to help shunt it back okay so we see all these changes occurring with our patient and while it may look like oh they look better they're not we understand this is a compensatory cycle and the patient will not continue to go well we still have all our compensatory mechanisms trying to work we're increasing white blood cells so that we can try to continue to combat this pathogen as the patient progresses they go into what we call the late slash cold slash uncompensated slash whatever you want to call it we're not doing good phase late face cold face uncompensated base hypodynamic phase whatever they all mean the same thing we've progressed into a state of shock now where the body no longer is able to help itself so we're not going to see that cardiac output that's rising it's going to go down we're going to see pulses become thready and weak my patient is at this point most likely not responsive anymore i've lost urine output i don't have any more my clotting values continue to be skewed my renal function continues to get higher this dysfunction continues to show you on your higher higher body lab values your clotting factors are being depleted and your patients become really sick they look bad at this phase like you can look across the unit and use they're gray dusky or regardless of their complexion you'll you'll know not a healthy color they look this way okay so this is our latter phase what about you glucose remember all of our compensation makeup mechanisms are failing what happens to my white count all my compensatory mechanisms are failing now so what do we need to do you guys if you are running around with a nail in your tire and every day you choose to go put more air in the tire as opposed to taking the nail out are you ever going to get over having to put air in your tire no medicine is going to be focusing on taking the nail out of the tire let's find the culprit who's doing this and let's get rid of it who's the problem and let's get rid of it because until we take the nail out of the tire we cannot expect anything to ever get better we're going to be continuing this nasty little cycle we've got to treat the cause so medicines primarily focus on get who's done this who caused this situation what are we going to be as nurses we're going to be making sure that we're implementing orders in a timely fashion and if we don't have them we're going to be asking for them because i want you to look again i don't remember my statistics but i want you to think about this and take personal accountability every hour you delay getting your antibiotic on board what is it doing to your patient's mortality right every hour 5 if that's my audrey or my matthew i'm not going to be happy with you right if that's something you love you're not going to be happy about that are you and you guys don't think in this day and age that people won't know these things they can google everything and this is a true story i saw it happen myself had a man come out his son was very sick he came out he had googled treatment of septic shock and he knew that that provider said that i had ordered his antibiotics this morning and provided or told him antibiotics here it is hours and hours later they had not initiated antibiotic therapy he was lifted rightfully so does the nurse have anything to stand on no no what was your excuse you've got to get so if you don't have an order for an antibiotic and the blood cultural results are back isn't it your responsibility to communicate that and this is what they're going to do guys so blood cultures are drawn as soon as they're obtained while they're waiting on the results because it's going to take a while they're going to put them on a broad spectrum once they've identified who it really is they'll implement a targeted measure towards that specific pathogen but in the meantime we've started coverage for the patient okay but every hour we delay getting that on board we're increasing our patient's mortality rate that's not acceptable look what happens if you delay your fluid resuscitation mortality rate goes up to seven percent every hour and i want you to think about how fast an hour goes by flies by doesn't it it's like boom gone it's not always that it's intentional that nurses get behind someone they're just caught up in all this what's going on but you've got to be mindful of that you have to okay and take responsibility of that now nutrition and remember in your skills modules you're going to have a lot of i just told you after the test had a lot of fundamental models to do with those skills because this is what i'll look at back to the basics so what is what's the difference between internal and parental which what does intel mean sid what does the intro mean where am i going if you can't answer from a friend very good is going did y'all hear she's self-spoken so sweet she's going through the gi tract if we're doing internal feedings they're going via the gi tract pierce what does parenteral mean it's going through the gospels okay so parliamentarial we're in the iv enteral is going via the gi tract parenteral is going in the venous space which of those two do you think is best and then why answer that i want you to think back to fundamentals feeding the gi tract promotes what motility it maintains the structure and most importantly function what's the function of the gi tract to know when to absorb nutrients when to utilize them when to store them right now having said that what regulates a parental the pump now you tell me which of those two is better for the human body enteral without a doubt there's one time and one time only you're going to use parental nutrition and that's when we cannot safely go through the gi tract a couple of my students i know had patients that had quan i think you had a dylan last week that had the bowel issue you remember that and then one of my two ladies didn't one of you all have one yesterday you did we can't use the gi tract it's not safe there's either an obstruction there's a mass there's a there's a huge wound there it's not moving it's not safe to go through the gi tract and that is the only time we're going to get parental okay otherwise we're going to use enteral nutrition and remember you guys the stomach is like a timex watch it will take a lot of hurt and it's there's this old saying put your dog and your wife in the trunk and see who's happy to see you when you open it back up you don't want to get your wife's like you should have kept that shut because while i was in here i was making a weapon your gi tract is very forgiving your stomach is very forgiving it will do without perfusion for a while and it will resume function very readily okay and it even in a situation where all of our organs are failing your stomach tends to keep trying to work for you so thank you okay the gi tract is always preferred over perennial nutrition the only time we use perennial is when we cannot use the gi tract and i'm spending time on this on purpose you'll see with that comes you know what are the risks associated with parental nutrition what's one of the biggest risks associated with parental nutrition infection well we don't need that now okay plus a pump regulates how many amino acids are going to be delivered how much glucose is going to be delivered etc etc etc whereas the gi tract knows hey i don't need those amino acids right now i'm going to store those a little while okay and again that's why the benefit how early do we need to institute nutrition within the first day or two minimum again that's your responsibility have you investigated that have you looked at that said man we haven't been feeding this patient it's been day two we need to be doing something about this because without adequate nutrition what is your cell function going to do it's going to decline it can't function it's got to have energy to do its job okay nursing aseptic technique you're going to be really diligent with this patient who's either at risk or any patient right am i not going to be careful with any patient that i'm not introducing pathogens um frequent vital signs does anybody have to tell me how often to do them what do you think would be your minimum vital sign assessment here time frame could be but every hour will be minimal if i've got a patient who's in dire straits it might be every few minutes okay but q1 hour vital signs at bare minimum um constant head to toes making sure you're implementing your treatments right on time and monitoring all your lab values and again if you've got a pa catheter this is an awesome thing but we're not going to put one in unless they already had one why would we not put one in or increase infection risk but jay and jessica you guys got to see a float track yesterday far less invasive device it can be done through a probe or an a line and it gives me those values i can still see my cardiac output my cardiac index my svr my stroke volume my cbp with this really cool device called a flow track that's not near as invasive um medications okay so while we said that steroids can lead to this remember that was because in the early phases we needed a healthy immune response and not having something that would start a localized inflammatory response is a bad thing because that will permit the pathogen to run rampant but now that the pathogen is rampant i need to slow that response down because systemically it's dead that is lethal so steroids are not at all unusual um narcan i personally have not seen it used but narcan is theorized to reduce endorphin-mediated vasodilation so let's just think about that for a minute when i was younger i ran i ran until i was pregnant with my daughter about five months and broke my foot you know when you're pregnant there's not a lot you can take for a broken foot and it hurt like a dickens and um that it kind of stopped my running days i do the walking instead but anyway back to what i'm saying i never got that what they call runner's highs like i don't know what these people are talking about and i've been running for years and i've never got that oh i just i just want to keep going i loved running because it was a de-stressor but i can't say i ever felt that euphoria whatever somebody did not me but endorphins would have been what would have created that okay well with endorphin release you have vasodilation when you're under severe physiological stress we try to intrinsically kind of protect that brain like oh you've got a lot going on maybe you just kind of don't need that real big picture here or release some endorphins so you feel a little bit better but when we do that it drops blood pressure so narcan reverses this action we know that under extreme physiological stress i notice i didn't say psychological i said physiological there's going to be endorphin release and we don't need that because it's going to further mediate vasodilation so let's instead give them the narcan which will stop that again i've personally not seen that implemented but that's why it's being what's theoretically good okay um we talked about our vasopressor already norepinephrine vasopressin is another form of vasopressor it's usually your second line they can be up to three vasopressors at one time folks if i've got a patient's not responding to one adequately and we're on a max dose we need to add another we might need to add a third so your vasopressors um fomodivine and your paniprozole we've got ppi h2 blockers etcetera because we talked about that physiological stress induced hydrogen ion production we want to prevent stress induced ulcers and then low vanox okay this gets tricky ricky and i'm going to build on it when we get to dic but i want to refresh your memory on something that's happening right now we talked about cellular destruction at the endothelial level remember right and which increases lactate levels because of the poor perfusion to the organs well all those little micro clots that develop there with fibrin because there's areas of injury now the body thinks well i guess i need to go fix this too we've got fibrin aggregating what does aggregate mean come together we've got fibrin aggregating at the endothelial level which is depleting my fibrin stores and further compromising organ perfusion when we do the vte prophylaxis which we would do anyway because our patient's definitely not walking around right now it also this low molecular weight heparin or heparin itself also helps slow down that fibrin aggregation which kind of in essence in a layman's terms way saying this helps maintain your stores where you need them like around your iv site around your endotocal tube cuff your foley catheter etc okay so what are some complications your patient is going to develop adult respiratory distress syndrome this is because of fluid entering spaces you couldn't enter before we have profound compromised gas exchange we're going to go into greater detail on ours on module b dic which i'm going to revisit again in a minute disseminated intravascular coagulation acute renal failure gi blade heart failure if your heart's not perfusing itself it's not going to continue to be able to function accurately which is why again while your cardiac output also drops and then therefore it's going to lead to that dysfunction central nervous system dysfunction we've got to have perfusion to the brain the liver is eventually going to fail and ultimately as all these organs are one by one clocking out your patient's not going to survive it's a grim outlook once we get to that later phase of shock their prognosis becomes very poor so dic disseminated intravascular coagulation there's something up here in big green and then up there in bold letters a patient is not going to come in with a diagnosis of dic and nothing else dic is always in a response to something else it's never primary it's always secondary so if something's secondary what do you need to treat the secondary or the primary that's right you've got to get the nail out of the tire you're not going to be able to fix this problem you're not in other words you can't fix dic until you fix what caused the ic so treatments are going to be primarily aimed at eliminating the cause what we do for the dic is not really treating the dic it's buying us some time this is so you can look through half though what does the patient in dic look like where you're going to start seeing very large bruised areas that don't look you know they're like okay that's not a normal rose that is full thickness what's going on there you're gonna start to start bleeding from places you shouldn't see bleeding from like around your iv sites your foley catheters will have blood coming back in it your central line will have blood building up around it the eyes you're going to start seeing bleeding in places we shouldn't see bleeding before before what's happened we've depleted our vibrant it's all in these little endothelial areas and we don't have any more stores remember those bleeding times got skewed from the hepatic dysfunction at our values so they're gonna they can do these different things but it's not gonna cure anything except this the only thing that's gonna cure dic is get rid of what's caused it these things right here just to try to buy some time sometimes okay and don't get confused about okay you're like well why does it say give them heparin but here we're going to give them vitamin k remember there's different mechanisms of clotting aren't there is vitamin k gonna help maintain a normal ptt no because of different parts of the clotting cascade the heparin is going to buy us some time by by storing fibrin not allowing it to be utilized so quickly whereas the vitamin k is going to stop that other factor part that goes along with that clotting part that part of the chlorine cascade we may try replacing the patient's plasma plasmapheresis giving them platelets cryoprecipitate fresh frozen plasma but none of that is going to cure the patient none of that's going to cure that dic when you get dic folks you can't you've got a really bad you're in a bad place with patients their their prognosis is incredibly poor at this point here's just some more pictures of what it looks like and the consequences of it okay see all this bleeding around the eye i don't know this drives me crazy i say every single time i teach this they shouldn't put the same two different people's tootsies clearly they're only different you should have a comparison here the same person's it will show you the differences okay anyway whatever but you can see what it was not perfused okay um labs the state board knows there's no way you can memorize every lab value in that book which is why you have references however there are some labs that they expect you to have committed to memory like your basic chem panel glucose levels basic bleeding times like what is your normal inr what is your normal pt what is your normal ptt and those i would know for this exam what are those normal values a d dimer that is elevated tells me what as a nurse we don't know where it's not going to tell me where the clock is but it's going to say hey there's a clot somewhere in that body it may be a pe maybe a dvt maybe multiple mli it's like you've got clot or clots somewhere cockatoo it doesn't tell me where the inflammation is but there's an inflammatory process going on somewhere so d dahmer's elevated remember we talked about lactate levels already it's not going to want you expect you to know what an antithrombin 3 level is i don't know what the normal is for that i've been doing this 35 years i'd have to look at a reference range and the state board exam knows that too that's one of those little random labs you're like huh they know that okay they want you to know your basic values um look at our fibrinogen really depleted here remember we talked about fibrin has been utilized at that endothelial level further compromising perfusion and what do i have now depleted levels and that's robbing it from the places i needed it to be okay so look over your basic normal lab values that i've discussed as this happens again all your organs are starting to shut down we call that mods multi-organ dysfunction syndrome and you know this is so hard because what you're trying to do is help one thing but if this this one organ system can't sustain a body it needs a collaborative effort from the other organs and when they're all shutting down it's a really dismal situation okay all these organs are shutting down your lungs will be the first to show signs don't look at seven to ten days i've seen people change overnight okay that's just the grand scheme of things how can this take place okay don't memorize those things your lungs are usually the first show signs you're going to start hearing crackles like what the heck is going on here and you're going to start seeing a change in your saturation levels like what's going on here why am i requiring more oxygen what is your patient going to do when they start having a reduction of their oxygen saturation level how they start acting they're going to start acting like they're restless good good word anxious restless when you are when your brain detects some hypoxia setting in you starting to you're starting there's a there's that sympathetic stimulation like what wait a minute no we got we have a fight here cause something's going on don't know what it is okay so a little bit of restlessness anxiety um and then everything starts to shut down one by one tss is in this module too because it is a form of septic shock it's just a little different by nature because a we know exactly what the pathogen is b we know who our patient population is very specifically and c we know what triggered it what caused it so it's a form of septic shock but with some very specified criteria treatment of my patient is going to be the same essentially the same so your school nurse and you've got little girls remember the higher the bmi of the child the earlier they're going to start their cycle okay so you can have a 10 year old who's already started a menstrual cycle that 10 year old little girl has mama who's a crackhead and daddy who's missing who's teaching that 10 year old little girl how to use her tampon who her little 11 year old friend who's in the same situation now your responsibilities as a school nurse are to make sure your children are educated you're not giving them permission to wear a tampon my mother had very strict religious beliefs i was raised roman catholic and as well said nothing goes there about your husband and cleaning a tampon when they first came out okay that was just you know she was like oh no oh no we respect parents values but what do we tell them we're not telling them it's okay to use that their parents if this is something that goes against their religious beliefs or their cultural beliefs but we are going to educate them on what's proper as far as care and how to use it should they choose to what do we need to teach those children yes because when these first came out we didn't have any data we didn't know because we they were new they were awesome and trust me as soon as i moved out of my mom and daddy's house i bought them now i'm way past that age just one past one aisle walmart i'm just like see ya but yeah i was like okay whatever mama this is much more convenient i'm on my feet for 12 15 hours a day i got time to be studying all that stuff but as data became available to us what do we find out but the longer they dwelled staff is naturally present there is it not it's on your skin now it kind of grows don't look it under the microscope you'll be heavy get out you're like oh my bath i took a bath there's stuff there well we found that the longer they dwelled in that warm dark moist environment the pathogen flourished and what was normal flora now became a primary pathogen and our patients became very sick so they present with flu-like symptoms they did a lot of research like well they have a common they're all menstrual aids they're all female they all had tampons in during that time frame boom we came up with a conclusion now i think the box is telling you don't they ladies and gentlemen preparation age you know how i know but you know that's really sad it's not commercial say don't take this if you're allergic to it right i'm sorry but that's a sad day when we have to tell people if you're allergic to us don't take this anyway back to where we were we came with a common denominator so my job as a school nurse is not to infringe on the religious or cultural beliefs of anybody but i do have an obligation for my licensure to educate not give consent but to educate i want to make sure my little girls are safe so we're going to talk to them about how often to change it give them you know tangible times you know every time you change your second class it's time to go to the restroom and change your product whatever okay um so our patient's presented with those that ache what does general malaise what does that mean that's the case of i don't feel good you know what i'm saying i got general delays if you want to press people like i got general malays on they don't feel good they had a fever they had a rash now that rash was a little more specific here and that was related to that staff okay otherwise same cascade hypotension and away we go okay and we have a septic patient okay well we'll say about that um we did it so you're going to go back and do what guys i think that was it that's the last one is there one more slide oh yeah whatever okay we're there we're done okay so you're gonna go back now guys let me tell you something i'm a firm believer in this too you control your future i told you guys i'm the first member of my family to have a college education my sister was the second you control your own future you take control of it and you seize it and you do something about it so instead of licking wounds from today if you did not achieve the score you needed that's done it's behind us there's nothing we can fix about that now all we can do is take control of what that's right now and tomorrow what am i going to do about it now so you're going to go back and look at what do you need to refresh yourself on what do i need to work on you're gonna go back to those hemodynamic values we discussed especially which one cbp because we've talked about that already today you're going to go back and review the inflammatory response so you truly understand what's happening again if you don't know what happens under normal situations you are never going to understand what you're seeing happening in your patient or how these treatments are going to change that you've got a lot of ati work seize it and get busy with it don't try to check boxes you know what i'm saying when i say check boxes cool i'm done with that that's right you're just clicking and going you're not helping yourself i want to see i'm going to use pierce as an example i want to see evidence of how hard you've been working based on a question he presented the other day it was obvious no way could he have formulated those questions without having put forth a tremendous amount of work he could not have even intelligently discussed that well i was able to do that because he has been preparing i'm not singling him out and many of you guys are doing a great job in here okay many of you are as it was by your grades today but if you refuse to take ownership of your outcomes it's just going to invite you and you only okay so let's get busy let's work really hard on it don't don't wait till last minute what happens at the last minute ati may go down they may be updating their server who knows it's too late uh-huh what time does ati today when i get back to my office i'm opening it up okay if you don't see it by this afternoon 3 30 shoot me an email all the skills modules oh yeah that may not be i'll try it today but that probably more likely monday okay it just depends on how much i got to do when i get back to my office i got a lot going on right now okay but i'll open ati first before i even eat my lunch okay all right guys any questions is it thursday is that right today's thursday okay good that means you got a weekend coming up okay use your time wisely pace yourself accordingly you what are you going to review before you come to doctor neil's class on tuesday dr neal does f so little electrolytes get busy okay go ahead and start reviewing her parkland formula and um rule of nines okay parkland formula rule of nines go ahead and be reviewing that so when she talks about it for the first time you're not sitting there thinking what okay all right y'all have a good afternoon