Septic Shock Pathophysiology, Stress Response, and Geriatric Sepsis Care NUR4018

Describe the pathophysiology of septic shock and how this leads to a reduction in blood pressure

Septic shock is an acute severe disease that results from the infection, which triggers the bodys inflammatory reaction and causes tissue damage to multiple organs (Font et al., 2020). Sepsis is a condition characterized by the bodys response to an infection and the development of systemic inflammatory response syndrome, with the ultimate end being that the individual reaches a state of septic shock and hypotension (Font et al., 2020). Firstly, the development of septic shock starts with the introduction of invading microorganisms, for example bacteria or fungi into the blood or tissues. These pathogens secrete toxins often called endotoxins when they are from gram-negative bacteria or exotoxins from gram-positive bacteria that cause the activation of the immune systems inflammation process (Font et al., 2020).

In case of Mrs. Sally Johnson, there is a clear progression towards septic shock based on the clients clinical data and the chain of events leading to a decrease in blood pressure. For example, in response to the urinary tract infection, lymphocytes and other immune cells produce chemicals which bring an inflammatory response to Mrs. Johnsons body (Hsiao et al., 2020). This inflammatory cascade results to secretion various agents which include cytokines like, TNF alpha, IL1, IL6 and various other inflammatory agents (Hsiao et al., 2020). Corticosteroids, these mediators result in the vasodilation of blood vessels in various tissues of the body (Kuwabara et al., 2022). Cytokines are considered as one of the primary agents responsible for septic shock and the general systemic inflammatory response. They cause vasodilatation in large part through the synthesis of nitric oxide (NO) and prostaglandins (Kuwabara et al., 2022). Vasodilation results to widening of blood vessels all over the body including arteriolar lumens and venules. This dilation leads to a decrease in an important factor that defines the blood pressure, the systemic vascular resistance (SVR) (Font et al., 2020).

When the blood vessels dilate and besides becoming flaccid; they also become permeable to certain substances. They enable fluid instead to filter from the blood vessels into the interstitium and therefore lead to reduction in intravascular volume (Leone et al., 2023). Reduced cellular oncotic pressure leading to less fluid reabsorption from interstitium back to the vascular compartment results to a decrease in preload or volume of blood returning to the heart hence lowering the cardiac output (Leone et al., 2023). At the same time, the inflammatory cascade initiates the coagulation cycle with the formation of a complex of factors activated thrombin (Font et al., 2020). It was described that this activation can cause disseminated intravascular coagulation (DIC) and consume clotting factors and form small clots in the peripheral microvasculature (Font et al., 2020).

Describe how the stress response can impact on the blood glucose levels of a person when they have an infection

Due to infection and septic shock in Mrs. Sally Johnson, her bodys stress response is elicited. Cortisol increases the levels of glucose in the blood though it enhances the synthesis of glucose through gluconeogenesis from non-carbohydrate precursors predominantly in the liver (Kushimoto et al., 2020). Epinephrine or Adrenaline and Norepinephrine or Noradrenaline activates glycogenolysis which convert glycogen to glucose for energy. Besides, the infection-induced inflammatory response and cytokines lead to insulin intolerance, which decreases glucose uptake in tissues (Kushimoto et al., 2020). Collectively, these influence hyperglycaemia which worsens metabolic fluctuations or imbalance and has consequently affected the condition and or progress of Mrs. Johnson.

• Hormonal Response: When the body detects an infection, the stress response activates which involves the hormones such as cortisol, glucagon, as well as the catecholamines including the epinephrine and norepinephrine. These hormones help in calling the energy from stored up energy reserves in the fight against foreign organisms that causes diseases in the body (Kushimoto et al., 2020).

• Glucose Release: Cortisol and glucagon are hormones that mobilise the liver to release glucose which is stored in the form of glycogen through glycogenolysis. This in turn helps to make more glucose available to the circulating immune cells as well as the tissues to help them combating the infection (Wasyluk & Zwolak, 2021). Adrenaline also contributes to glycogenolysis whereby glycogen (stored glucose) in the liver and muscles is broken down into glucose further increasing the concentration of glucose in blood stream. This response offers an immediate energy supply when the metabolic rate is boosted by an infection (Wasyluk & Zwolak, 2021).

• Glucose Production: Cortisol also brings about glycogenolysis and in addition also promotes gluconeogenesis which is the creation of glucose from compounds that are not carbohydrates such as amino acids and glycerol. To enhance this, blood glucose level is elevated again in order to cater for the energy needs for the immune cells during infection and inflammation (Wasyluk & Zwolak, 2021).

• Insulin Resistance: In the stress response, the resistance of cells to insulin, where cells are not affected in the same way by insulin, can happen. Insulin usually assists cells to transport glucose from the blood into the cells. In insulin resistance, there is the declined removal of glucose by muscle and fat cells hence create high blood glucose level despite normal insulin levels during any infection or pathogen present in the body (Rivas & Nugent, 2021).

• Impact of Inflammatory Cytokines: Infections also activate the release of inflammatory cytokines that include TNF-alpha, IL-1 and IL-6 among others. These cytokines can induce insulin resistance and can stimulate the glucose production at the liver thus the existing hyperglycaemic condition occurs during the infection in the body (Kushimoto et al., 2020).

Identify one age related physiological change and discuss how this could impact on the presentation of sepsis in the older person

Immunosenescence is a crucial factor in the way Mrs. Sally Johnson's body reacts to the UTI in her 75-year-old instance. She is exhibiting signs of sepsis and confusion. Immunosenescence means an unbalanced and hostile immune system which does make elderly individuals more prone to dangerous infections, awful sepsis, autoimmune diseases, and malignancies (Agrawal & Weinberger, 2022). With individuals age, several changes in the immune system contribute to immunosenescence:

• Reduced T Cell Function: T cells, which are vital for the identification of precise pathogen combaters, are less sensitive to such approaches in later years. This reduces the efficiency of clearing infections hence a significant factor in pathophysiology (Liu et al., 2023).

• Impaired B Cell Response: It has been observed that B cells which secrete antibodies may lack diverse and efficient production as in the case of elder people. This may result to the development of slow and blunt antibody formation against new infections within the body (Liu et al., 2023).

• Decreased Innate Immune Function: Some of the cells of the innate immunity including the neutrophils and macrophages may become less active and less effective in the phagocytosis and destruction of microbes (Liu et al., 2023).

• Comorbidities and Frailty: Essentials of Geriatric Medicine is that older adults have multiple comorbidities like diabetes, cardiovascular disease, or may be frail, and all of which drastically weaken the immune system to fight off infections leading to septic shock (Liu et al., 2023).

Immunosenescence has profound effects on sepsis presentation in the older individuals such as delay in the identification of the sepsis, increased prevalence of the infections, difficulty in diagnosis and management of the disease, high mortality and morbidity index etc (Agrawal & Weinberger, 2022). Old people often relatively asymptomatic infections due to the immunosuppressed condition. Purulent inflammation may not be marked by fever, and in the reverse, fever may be absent, high fever dramatically reduced; there will be no leucocytosis (Agrawal & Weinberger, 2022). This makes the patients vulnerable to infections originating from bacterial, viral, or fungal sources that may eventually cause sepsis. They get infected more easily than younger people and go to septic shock much faster (Agrawal & Weinberger, 2022). Sepsis in older patients is mostly accompanied with comorbidity and pre-existing frail health, which contributes to diagnostic and therapeutic challenges (Agrawal & Weinberger, 2022). The development of co-morbid conditions may obscure sepsis or mimic the clinical picture of the condition thus delaying diagnosis and treatment (Liu et al., 2023). Patients of older age with sepsis have higher mortality than younger patients due to pre-existing diseases, debility, and immunosuppression. It was also identified that older age group have higher risk of long-term functional decline and subsequent cognitive impairment (Liu et al., 2023).

Describe one collaborative care team member and justify how their role would support the patient and their discharge home

An important member of the collaborative care team for facilitating Mrs. Sally Johnson to go home after discharge is the Geriatrician. Geriatricians are physicians that are trained to deal with elderly patients and their medical complications, dementia, frailty, and other conditions that come with aging (Kojima et al., 2020). Geriatricians conduct comprehensive medical, nursing, and psychiatric histories, as well as physical examinations that may identify Mrs. Johnsons health, medical, psychiatric, medication and functional status including her chronic conditions, that include diabetes, osteoarthritis, and GERD (Kojima et al., 2020). They will admire how her recent urinary tract infection (UTI) will influence her current confusion, as well as the worsening of other ailments. Mrs. Johnson has more than one chronic disease; all these conditions need to be taken into consideration when managing the patient (Kojima et al., 2020). They will make sure that her management plan covers not only the acute developing UTI but also the diabetes management, the pain from osteoarthritis, and GERD for proper holistic care (Kojima et al., 2020). Because Mrs. Johnson has severe confusion, the geriatrician will do cognitive assessment test to evaluate the patient cognitive status. They will exclude whether her confusion is because of delirium or worsening of underlying dementia, effects of a medication she may be on or other factors (Romskaug et al., 2020). The geriatrician is a case manager who works with other members of the healthcare team, which includes nurses, pharmacists, social workers, and colleagues from the allied health disciplines (Southerland et al., 2020). Geriatrician ensures that the care plan is comprehensive, focused on all domains for fast recovery of Mrs Johnson health. Before discharge, Mrs. Johnsons main care requires a geriatrician who will coordinate for a safe discharge from hospital to home. Also, health education should be given by the geriatrician on how to manage her medications as well as how to observe potential complications so that Mrs. Johnson and her family can be well equipped on what to do as they engage in self-care (Southerland et al., 2020). Geriatricians involve Mrs. Johnson and her daughter in her care through teaching her the nature of the medical conditions she has, the stable and necessary medication usage, methods of dealing with change in behaviour due to the diseases, and other symptoms that she should look for as indicate further complications at home (Southerland et al., 2020). After Mrs. Johnsons discharge, the geriatrician helps her to make arrangements to follow up with her general practitioner and her specialist doctors. The staff observe her condition frequently, report if there are any persisting complications or new developments, and redesign the care plan to promote acceptable results and avoid hospitalization (Romskaug et al., 2020).

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