Shock describes a life-threatening body state characterized by circulatory failure. This condition causes inadequate oxygen supply for cellular metabolism and consumption needs, resulting in tissue and cellular hypoxia (reference). While the initial effects of shock are reversible, they rapidly advance to irreversible, leading to a multiorgan failure (MOF) and eventual death (Gaieski & Mikkelsen, 2018). Therefore, it is imperative that clinicians promptly initiate therapy whenever an undifferentiated shock condition is presented. Such rapid interventions would facilitate the administration of definitive therapy to reverse the condition and prevent MOFs and deaths. This paper describes how nurses can leverage the Canadian Association of Critical Care Nurses (CACCN) standards to ensure a collaborative approach to managing critically ill patients afflicted by shock. The discussion encompasses a brief overview of the pathophysiology of shock as well as the etiology and medical presentation of the selected type of shock.
Pathophysiology and Progression of Shock
In physiology, shock refers to the failure of the blood circulatory system to supply adequate blood to peripheral nerves for basic metabolic needs, including the supply of oxygen and nutrients and the removal of waste from tissues (Gaieski & Mikkelsen, 2018). Shock results from various physiological mechanisms, including an abrupt drop in blood volume, like in cases of severe hemorrhage, reduced cardiac output as in heart attacks, and prevalent blood vessel dilation, like in some forms of infections (EMS 101, 2020). Whatever the causal mechanism, the shock effect remains the deprived flow of blood through the small blood vessels through which oxygen and nutrients are supplied, and waste is removed from the body tissues. In most cases, the disease is characterized by low blood pressure, feeble, rapid pulse, and cold, sweaty skin (Gaieski & Mikkelsen, 2018). Depending on the causal mechanism, some or all of these symptoms may be absent in some cases.
The clinical types of shock include hypovolemic, cardiogenic, septic, anaphylactic, and neurogenic (Sarwar, 2018). These different types of shock present complete and complex pathophysiologic processes with various other mediators. Shock is a progressive blood circulation abnormality with changing physiological patterns. Albeit the differentiation in the pathophysiology of the different types of shock, the final pathway is similar involving deprived perfusion, anaerobic metabolism, lactic acidosis, and mediator release with irreversible tissue impairment (Sarwar, 2018). Shock progresses in three stages: stage I, also called nonprogressive (compensated stage); stage II, also known as progressive (decompensated stage); and stage III, the irreversible phase (Sarwar, 2018).
Type Selected and the Rationale
The main challenge with treating shock is identifying the cause of the problem, as several sources of shock can coexist in one case, particularly after an accident. Failure to distinguish the specific cause of shock can result in therapeutic trauma, as treatments for one type could be aggravators for another. Thus, understanding type-specific pathophysiologic changes are essential for accurate diagnosis and appropriate therapy. This paper is based on septic shock as the type selected for analysis and application of CACCN standards. The selection rationale revolved around considering the relatively high prevalence of septic shock, necessitating urgent interventions to promote collaboration in care provision to reduce its high morbidity and resultant mortalities.
Etiology of Septic Shock
Sepsis is a disease that occurs when the human immune system is compromised from reacting to infections. The devastating diagnosis accounts for over 750,000 hospitalization and 200,000 deaths in the U.S annually (Gavelli et al., 2021). Sepsis progresses in three stages; sepsis, severe sepsis, and septic shock. Septic shock is the last and most severe stage of sepsis, characterized by shallow blood pressure despite intravenous (IV) fluids compensation. Additional symptoms of septic shock include light-headedness, little to no urine output, skin rash, heart palpitations, and cold, pale limbs (Gavelli et al., 2021). Any infection with the potential to cause enough inflammation can advance to sepsis, which then can progress to septic shock. Nonetheless, not all infections will develop into this type of shock. Most infections that result in septic shock are bacterial, but both fungi and viruses have lower chances of causing infections leading to the disease. According to Gavelli et al. (2021), common causative sites of septic shock include gastrointestinal tracts, lungs, biliary, and urinary tracks.
Immunocompromised patients and those with chronic conditions like leukemia, diabetes, and AIDS risk developing septic shock. People with weak immune systems include neonates, older people above 65 years, pregnant women, recreational drug users, and people with heart valves or artificial joints (Font et al., 2020). Moreover, patients who have recently had surgery, transplant, and infections are more exposed to septic shock.
While the pathogenesis of septic shock is not comprehensively understood, the basics infer that inflammatory stimulus triggers the release of cytokines such as tumor necrosis factor (TNF) and interleukin (IL)-1. These mediators cause the adhesion of neutrophil–endothelial cells, microthrombi release, and clotting mechanism activation. The cytokines are opposed by IL-4 and IL-10, anti-inflammatory mediators, resulting in a negative feedback mechanism (Font et al., 2020). Initially, the blood vessels dilate, lowering peripheral arterial resistance, and cardiac output increases at this point, usually known as a warm shock (Font et al., 2020). If the situation is left unaddressed, cardiac output decreases, blood pressure falls, and the typical symptoms of shock manifest. The body tissues suffer low oxygen supply, impairing the supply of nutrients and removing waste products, including carbon dioxide. Continuous perfusion eventually leads to organ failure, such as in the brain, kidney, heart, lungs, and liver (Font et al., 2020).
Clinicians can suspect septic shock if a patient with an infection abruptly develops hypothermia, low blood pressure, and rapid heart and breathing rates. Further blood tests when diagnosing septic shock include complete blood count, bacterial infection, blood oxygen levels, organ malfunction, and blood chemistry such as lactate. The health practitioner may also collect cerebrospinal fluid, saliva, and urine for further tests. Furthermore, imaging tests like X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) scan may be necessary to find the source of the infection (Cleveland Clinic, n.d.).
Septic shock requires immediate treatment in intensive care units (ICUs). The treatment of septic shock encompasses four equally essential objectives that run concomitantly. These include treatment of the disease, management of the state, compensation for metabolic acid-base imbalance, and reparation of nutritional deficit (Thompson et al., 2019). The immediate intervention for the condition is the administration of antibiotics and IV fluids to rehydrate the body and increase blood pressure. Treatment for patients experiencing breathing difficulties may involve oxygen supplements through ventilators or nasal cannulas (Cleveland Clinic, n.d.). In addition, surgery may be needed to remove areas infected, dead tissue, catheters, and other artificial medical devices that may have triggered the infection. In cases where fluids do not increase blood pressure as expected, medications such as vasopressin or norepinephrine are administered to cause a narrowing effect on blood vessels, thus increasing the blood flow (Cleveland Clinic, n.d.). Additionally, corticosteroids could be administered oi the medications and fluids fail to increase blood pressure. Patients also receive insulin when septic shock increases glucose levels (Thompson et al., 2019).
CACCN Standard 6
Standard 6 of the CACCN offers six defined criteria on how nurses leverage interprofessional teams and families to foster a collaborative approach to care provision. The second and third criteria were selected to demonstrate the importance of interprofessional collaboration in treating and managing the often-complex care requirements for patients afflicted by septic shock. These principles were chosen as they demonstrate core aspects of collaboration, including consultation, leadership, communication, and participation of all appropriate individuals, including professionals, patients, and their families. Besides, a root cause analysis showed communication failures, lack of collaboration, and ineffective teamwork as the leading causes of errors and events that risk the safety of service users.
The second standard underscores the importance of effective leadership, interpersonal communication, and conflict resolution skills in promoting positive interactions between colleagues, patients, and families. Effective clinical practices such as timely conflict resolution, interprofessional collaboration, and optimal patient safety entail good leadership, conflict resolution, and effective communication. Studies have shown that effective communication yields positive impacts on the healthcare system. For instance, Yeh et al. (2019) established that effective communication in healthcare significantly increased patient satisfaction, improved employees’ self-drive, enhanced information flow, interventions, and safety of service users. In addition, Müller et al. (2018) revealed that active communication increased handover quality and patient safety. This aspect is critical in treating and managing septic shock, as the condition requires continuous monitoring to prevent mortalities.
The third principle entails independent professional contributions and collaboration accountability to determine the best care based on evidence and competencies. Septic shock requires autonomous monitoring of vitals such as heart rate, urinary output, oxygen saturation, and blood pressure to inform patients’ hemodynamic status. As such, personal accountability is necessary to ensure that practitioners take up necessary actions depending on the changes realized in patients. Accountability for independent actions would help reduce human errors in diagnosis, treatment, follow-ups, monitoring, and medication. In addition, the principle supports interprofessional collaboration to ensure that patients afflicted by septic shock receive the best quality of care. No single professional can provide the highest standard of care to patients nor ensure that the service users are adequately protected from all potential harm. This implies that healthcare professionals must rely on each other and external agencies to deliver quality care and ensure safety. Therefore, professionals in the healthcare sector must acquire teamwork skills such as effective communication, trust and respect building, motivation, and good leadership. To improve a team’s effectiveness, selecting members who represent a broad and diverse range of skills and experience is critical.
Besides, teamworking is perceived as a contributing factor to interprofessional collaboration. According to Diggele et al. (2020), interprofessional collaboration fosters interactions among diverse healthcare professionals, enabling the implementation of skills, knowledge, values, and competencies into practice, thereby providing interprofessional care and improving service user outcomes. The appealing footing of IPC is that it improves the quality of care, reduces medical errors, lowers costs, reduces hospital stay durations, and enhances, service users’ safety. Teamwork would be particularly important in septic shock management as it would allow consultation and discussion among professionals to come up with the most suitable interventions based on the type and stage of the disease.
References
Cleveland Clinic. (n.d.). Septic shock: Causes, symptoms & treatment. https://my.clevelandclinic.org/health/diseases/23255-septic-shock
Diggele, C., Roberts, C., Burgess, A., & Mellis, C. (2020). Interprofessional education: tips for design and implementation. BMC Medical Education, 20(2), 1-6. https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-020-02286-z
EMS 101. (2020, July 31). A basic overview of shock for EMS. https://www.ems1.com/medical-clinical/articles/a-basic-overview-of-shock-for-ems-ruVOZ8HOYPTDeYCm/
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. https://doi.org/10.1016/j.mcna.2020.02.011
Gaieski, D. F., & Mikkelsen, M. E. (2018). Definition, classification, etiology, and pathophysiology of shock in adults. UpToDate, Waltham, MA. Accessed, 8, 17. https://www.medilib.ir/uptodate/show/1594
Gavelli, F., Castello, L. M., & Avanzi, G. C. (2021). Management of sepsis and septic shock in the emergency department. Internal and Emergency Medicine, 16(6), 1649-1661. https://link.springer.com/article/10.1007/s11739-021-02735-7
Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ open, 8(8), e022202. http://dx.doi.org/10.1136/bmjopen-2018-022202
Sarwar, A. (2018, December 9). Stages of shock – Made for medical. Made For Medical – Best Medical Lectures. https://www.madeformedical.com/stages-of-shock/
Thompson, K., Venkatesh, B., & Finfer, S. (2019). Sepsis and septic shock: current approaches to management. Internal medicine journal, 49(2), 160–170. https://doi.org/10.1111/imj.14199
Yeh, V. J. H., Sherwood, G., Durham, C. F., Kardong-Edgren, S., Schwartz, T. A., & Beeber, L. S. (2019). Online simulation-based mastery learning with deliberate practice: Developing interprofessional communication skill. Clinical Simulation in Nursing, pp. 32, 27–38. https://doi.org/10.1016/j.ecns.2019.04.005
write