Sepsis Notes K PDF

NUR 213 U5 Oxygenation, ARDS Septicemia, Septic Shock, DIC +-----------------------------------+-----------------------------------+ | Sepsis what is it? | Major worldwide problem, about | | | 50% of adults have heard of | |...

NUR 213 U5 Oxygenation, ARDS Septicemia, Septic Shock, DIC +-----------------------------------+-----------------------------------+ | Sepsis what is it? | Major worldwide problem, about | | | 50% of adults have heard of | | | sepsis, sepsis can turn fast and | | | assessment is what saves lives | | | more and having a good baseline. | | | Also, ways be looking for the | | | answer and teaching it. | | | | | | Sepsis is an extreme response to | | | infection that can cause tissue | | | damage, organ failure and death | | | if not treated promptly. | | | | | | \*\*Septic Shock is a subset of | | | sepsis and is associated with a | | | much higher risk of death. | +===================================+===================================+ | | More than 1.6 mill cases US, q2 | | | min someone dies from sepsis. | | | | | | They die of sepsis more in 1 year | | | than breast CA | | | | | | Ppl who receives dx of sepsis are | | | 75% stay of hospital | | | | | | Mental status changes, confusion, | | | | | | Abdominal sepsis, highest | | | mortality, only 30% survive- | | | prognoses are poor | | | | | | 20% account for sepsis, 50% of US | | | hospital deaths. Also, the amount | | | of hospital readmissions | | | | | | | +-----------------------------------+-----------------------------------+ | Surviving Sepsis | - Updated global adult sepsis | | | guidelines, released on | | | October 2021, by the | | | Surviving Sepsis Campaign | | | (SSC) | | | | | | - Increased emphasis on | | | improving the care of sepsis | | | patients after they are | | | discharged from the intensive | | | care unit (ICU) | | | | | | - Represent greater geographic | | | and gender diversity than | | | previous versions | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Chain of Infection | | | | | | Pathogen is the bacteria, | | | transported by air, water, soil, | | | tissue, body fluids, and objects | | | | | | Virus' enter cells | | | | | | Parasites- | | | | | | Pathogen-infectious agent | | | | | | Reservoir- people | | | | | | Portal of exit- how we infect | | | | | | Mode of transmission- how | | | | | | Portal of entry how it gets in | | | | | | Susceptible host- people | | +===================================+===================================+ | The Body's Response to infection | **Normal Response to Infection** | | | | | | - Local Infection | | | | | | - Non-specific inflammatory | | | response | | | | | | - 3 phases: | | | | | | - Vasodilation- increased | | | blood flow to the site, | | | infusion of antibodies | | | and cells to fight | | | infection | | | | | | - Vessel permeability- | | | antibodies and cells exit | | | bloodstream and enter | | | infected tissue | | | | | | - Once infection is | | | controlled, tissue | | | repairs itself | | | | | | In response to pathogen or | | | microorganism- increase blood | | | flow with capillary with | | | leukocytes to fight the infection | | | | | | Anti-inflammatory to help | | | maintain the balance, | | | | | | Cytokines- mediators recruit | | | immune cells to the injury- are | | | the key to pro inflammatory and | | | anti-inflammatory response | +-----------------------------------+-----------------------------------+ | Immune Response to infection | Normal Immune response | | | | | | - Arteriole dilation w/small | | | vein constriction | | | | | | - Capillary permeability | | | | | | - Pro-inflammatory mediators | | | (IL-1, IL-8, TNF) | | | | | | - Platelet activating | | | factor | | | | | | - Attract leukocytes and | | | Cytokines | | | | | | - Anti-inflammatory mediators | | | (IL-6, IL-10, APC) | | | | | | - Suppress inflammatory | | | mediators | | | | | | - Inhibit pro-coagulant | | | activity, increase | | | fibrinolysis | | | | | | - Arteriole dilation, blood to | | | the site, that is why we have | | | swelling, | | | | | | - Cap permeable. Make the | | | capillaries leaky | | | | | | - Anti inflame-suppress | | | inflammatory mediators and | | | increase the fibrinolysis- | | | clot busting (to break up | | | that clot) with the localized | | | infections or injuries | +-----------------------------------+-----------------------------------+ | Balance between Pro and |  | | Anti-inflammatory | | | | Result is homeostasis- | | | cytokines-mediators- their | | | purpose is to regulate and | | | suppress the immune system such | | | as an immune response such as | | | sepsis. | | | | | | In sepsis the end point is not | | | realized. | +-----------------------------------+-----------------------------------+ | Characteristics of local | - Organisms invade | | infection | | | | - Local inflammation response | | | aims to trap and eliminate | | | the organism, prevent | | | spreading | | | | | | - White Blood cells (WBC), | | | collect at the area and | | | secrete cytokines, prompting | | | more inflammation and more | | | WBCs to come and kill the | | | infecting organisms (pg. 741) | | | | | | - Causes local vasoconstriction | | | and causes local dilation of | | | arterioles, which increases | | | perfusion to the locally | | | infected tissues | | | | | | Organism that invades, leads to | | | local inflammation which leads | | | (arm with fire) to the WBC- | | | vasoconstriction of the local | | | arterioles | +-----------------------------------+-----------------------------------+ | Characteristics of Local | - Leading to increased | | infection Continued | perfusion to local infected | | | area | | | | | | - Capillaries leak plasma into | | | the tissue, causing edema at | | | the site, duration of the | | | inflammation depends on the | | | size and severity of the | | | infection. The benefit of the | | | inflammation is that limited | | | to only the area and stops as | | | it is no longer needed. | | | | | | - With Local Infection **NO:** | | | fever, tachycardia, decrease | | | in O2 sats, and decrease in | | | urine output. | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Characteristics of Systemic | - Organism invades the blood | | Infection | stream | | | | | | - The infection escapes local | | | control | | | | | | - Bacteria increases | | | | | | - Widespread inflammation | | | (systemic Inflammatory | | | Response system, AKA SIRS) | | | | | | Systemic infection- can be | | | infectious and noninfectious | | | infections. It can happen in | | | trauma; it is the response that | | | is associated with sepsis. | | | | | | Sepsis can be life threatening, | | | brought by a dysregulated | | | response to infection. Sepsis can | | | be cellular, circulatory, and | | | metabolic abnormalities. | | | | | | \*\*The inflammatory response can | | | be associated with sepsis, | | | inflammation becomes the enemy | | | leading to extensive hormonal, | | | tissue, and vascular changes and | | | oxidative stress that can further | | | impair gas exchange and tissue | | | perfusion. | +===================================+===================================+ | Characteristics of Systemic | Toxins now traveling in the blood | | Infection Continued | to organs causing: | | | | | | - Inflammation | | | | | | - Impaired gas exchange | | | | | | - Impaired tissue perfusion | | | | | | - Leads to s/s: Fever: | | | low-grade, high or none, Mild | | | Hypotension, Tachypnea, Low | | | urine output. | | | | | | - Decreased urine and increased | | | respiratory is compensatory | | | response to impaired gas | | | exchange and perfusion. | +-----------------------------------+-----------------------------------+ | **Sepsis: What is it?** | Sepsis: is an exaggerated immune | | | response to infection (bacterial, | | | viral, fungal) \*\*originate from | | | any tissue | | | | | | **Main Goals of Management** | | | | | | - Identify and Treat infection | | | | | | - Maintain Hemodynamics | | | stability | | | | | | - Prevent or minimize organ | | | damage | | | | | | **Sepsis or Septic Shock** | | | | | | - Immediate supportive Care | | | | | | - Begin searching for | | | underlying source of | | | infection | | | | | | | | | | | | Look at invaders, download | | | | | | Sepsis is a response to infection | | | that can lead to tissue damage, | | | organ failure, even if you | | | survive you may be left with | | | chronic pain or amputation. | | | Sepsis works quick. | | | | | | When you think sepsis, think | | | sewage tank. | | | | | | When sepsis turns into shock then | | | it will have decreased perfusion | | | and blood pressure. | | | | | | s/s may be difficult to | | | recognize: not afebrile | | | | | | Sepsis, when it enters the blood | | | system, and the immune system | | | goes haywire. Will have systemic | | | inflammation | | | | | | Procytokines: | +-----------------------------------+-----------------------------------+ Sepsis \| General Medicine \| El Camino \... +-----------------------------------+-----------------------------------+ | **Patho of | 1. Immune response triggered | | Sepsis** | | | | 2. WBC Fight release | | | inflammatory mediators | | | | | | 3. Vasodilation of Blood | | | Vessels, Capillary leak, | | | Blood Clotting | | | | | | 4. Decreased Perfusion to Organs | | | | | | 5. Metabolic Acidosis | | | | | | 6. Septic Shock | | | | | | 7. MODS | | | | | | Pathogen inter the blood stream | | | and the WBC fight and release the | | | cytokines (luekokines, and | | | others) look at the big signs of | | | sepsis and what do I do, and put | | | thigs together quickly. | | | | | | Vasodilatation in blood vessel | | | | | | Nitric oxide- vasodilator- makes | | | blood vessels larger. Capillaries | | | are letting blood and fluid | | | leaking interstitially (also | | | blood clots floating around), | | | will lead to drop in blood | | | pressure, which means not enough | | | blood to organs= metabolic | | | acidosis (pH becomes to low), | | | happens when the kidneys are not | | | able to remove toxins and there | | | is not enough blood to kidneys to | | | produce bicarb. | | | | | | Septic shock is a subset of | | | sepsis. And decrease O2 to | | | muscles. | | | | | | Septic shock, doesn't respond to | | | the fluid. We are reinstating the | | | fluid. **We are going to give 30 | | | mL/kg**, can be seen through an | | | Art line, watch the trends, | | | | | | Passive leg raise- | | | | | | Multiple Organ Dysfunction | | | syndrome | | | | | | Blood vessel leads to DIC and | | | ARDS | +===================================+===================================+ | Patho of Sepsis | **Infection** | | | | | Another way to look at it. | **Systemic Immune Response** | | | | | | **Chemical mediators released | | | from endothelium** | | | | | | - **Histamines** | | | | | | - **Prostaglandins** | | | | | | - **Cytokines-** | | | | | | - **Tissue Factor** | | | | | | - **Chemokines** | | | | | | **Vasodilation** | | | | | | **Capillary Leak** | | | | | | **Clotting Cascade Initiated** | | | | | | **Loss of Clotting facts | | | Uncontolled Bleeding** | | | | | | **Multiple Organ Dysfunction** | | | | | | **Uncontrolled Clotting and | | | Intervascular dehydration** | | | | | | **Impaired gas exchange & | | | Impaired perfusion** | | | | | | **Disseminated Intravascular | | | Coagulation (DIC)** | | | | | | **Prolonged corticosteroid | | | release** | | | | | | **Immune system failure** | | | | | | **DEATH** | | | | | | Another way to look at patho of | | | sepsis | | | | | | Infection, systemic immune | | | response, the chemical mediators, | | | and this vasodilates and helps in | | | the blood stream and capillaries | | | leak blood and fluid and then | | | clot. BP drops, blood is | | | swelling, and blood not being | | | able to reach the organs | | | | | | Organs don't get blood and start | | | to dying. Kidneys don't have | | | enough bicarb so then sepsis | | | occurs, and then sepsis doesn't | | | react to bolus of fluids | +-----------------------------------+-----------------------------------+ | **Cause of Sepsis** | Bacterial infections are the most | | | common: | | | | | | - Lung infection (Pneumonia) | | | | | | - UTI/Bowel infections | | | | | | - Gut infection/abdominal | | | infections | | | | | | - Skin infection- IV | | | injections, look at the arms, | | | feet especially with hygiene | | | and those that are drug | | | users) | +-----------------------------------+-----------------------------------+ | **Risk Factors:** | - Elderly or newborn | | | | | **Ask about pts medical Hx, | - Immunosuppression | | including recent illness, trauma, | | | invasive procedures, or chronic | - Injury or Surgery | | conditions, check the drugs (drug | | | regimen may also indicate a | - Chronic Illness | | disorder or problem that an | | | contribute to sepsis). ASA, | - Catheters and Tubing | | corticosteroids, Abx, Cancer | | | drugs** | - Central Lines | | | | | | - Ventilator Support | | | | | | Any devices that include skin | | | breakdown (central lines) what is | | | why they give abx | | | prophylactically before surgery, | | | also things that would get | | | hospital acquired | | | | | | Immuno: transplant. | | | | | | If you have sepsis then you may | | | get it again. | +-----------------------------------+-----------------------------------+ | **Who is at risk?** | - Pregnant Women | | | | | | - Neonates | | | | | | - The elderly | | | | | | - The immunosuppressed | | | | | | - Patients with Chronic Disease | | | | | | - Hospitalized Patients | | | | | | | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Primary Sepsis Prevention** | - Evaluate risks- age \>65 yrs. | | | Or \< 1 yr. | | | | | | - Aseptic technique when: | | | | | | - Invasive procedures | | | | | | - Nonintact skin/mucus | | | membranes | | | | | | - Discontinued when not needed: | | | | | | - Indwelling urinary | | | catheters | | | | | | - IV access (especially | | | central lines) | | | | | | - Ween patients off of the | | | ventilator | | | | | | - Prevention: | | | | | | - take good care of chronic | | | conditions | | | | | | - get recommended vaccines | | | | | | - Handwashing | | | | | | - Healthy living/self-care | | | | | | - Nutrition | | | | | | - Control infections | | | | | | - Look for early S/S of | | | infection: | | | | | | - High heart rate or low BP | | | | | | - Fever, or shivering, | | | feeling very cold | | | | | | - Confusion or | | | disorientation | | | | | | - Shortness of breath | | | | | | - Extreme pain or | | | discomfort | | | | | | - Clammy or sweaty skin | | | | | | - Monitor Abx use | | | | | | Primary education: for patients: | | | | | | Talk about handwashing | | | | | | Balance nutrition | | | | | | Recognize s/s local infection, | | | purulent drainage, UOP decrease, | | | fever, early detection, nurses | | | biggest job is early detection, | | | use antimicrobial soap, armpits, | | | groin area, and after petting | | | animals, 2x a day. | | | | | | People shouldn't change the | | | litter box if immune compromise, | | | change it daily, toxoplasma (1-5 | | | days to clean litter box) wear | | | gloves, | | | | | | Don't get anything | | | | | | Toothbrushes cleaned 2x a week | | | with bleach and/ or in the | | | dishwasher | | | | | | Avoid raw and undercooked meat | | | and eggs | | | | | | We are thinking about killing the | | | bacteria, people who are high | | | risk, immunocompromised. (**Look | | | over Chap. 20-Iggy**) | | | | | | For healthy people, use universal | | | precaution. | +===================================+===================================+ | Watch for temp higher or lower | | | than normal, infection (abscess), | | | mental decline, extremely ill, | | | severe pain, discomfort | | | | | | Time is tissue, (like stroke) | | | before we know it is a stoke we | | | act like they have one: same | | | thing with sepsis, | | +-----------------------------------+-----------------------------------+ | In the hospital: |  | | | | | Remove foleys | Make sure that you scrub the hub | | | for 15 seconds it is the friction | | Mouthcare for ventilated pts. | as well as the friction when you | | | are washing your hands. | | Aseptic technique for central | | | lines, Piccs, and Central lines, | | | when helping with insertion, | | | sterile procedure (like Vat team) | | | | | | Isolation: use universal care | | | | | | Abx given before surgery and | | | discontinued after surgery. | | | | | | Sterile dressing changes 24 hours | | | after surgery | | +-----------------------------------+-----------------------------------+ | **Secondary Prevention** | Isolation: | | | | | | - CDC Guidelines | | | | | | - Universal precautions | | | | | | Surgery | | | | | | - Antibiotics | | | | | | - Prior to surgery | | | | | | - D/C within 24 hours | | | | | | - Sterile dressing change | | | (48hrs) | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Sepsis Progression | 1. Systemic Inflammatory | | | Response Syndrome (SIRS): As | | GO OVER | bacteria increases, | | | widespread inflammation, SIRS | | Stage 1 is where we really want | can be present with | | to do the interventions. | infectious and noninfectiou | | | spathologies. | | | | | | - **SIRS criteria = 2/4 | | | of:** | | | | | | - Temp. 100.4 F or \90 RR\>20 | | | | | | - PACO\12,000 | | | | | | - or \10% band cells | | | | | | - Band Cells- Immature WBC | | | that release before they | | | are strong enough to | | | effect infection | | | | | | 2. Sepsis: 2 SIRS criteria + | | | known or suspected infection | | | | | | 3. Severe Sepsis: Sepsis + End | | | Organ Damage | | | | | | 4. Septic Shock: Severe Sepsis + | | | refractory (unresponsive) | | | hypotension | | | | | | 5. MODS: Multiple Organ | | | Dysfunctional Syndrome | | | | | | - Organ Failures and Death | | | | | | To meet SIRS criteria you need 2 | | | out of 4 (triangle \#1) | | | | | | Band cell- immature WBC, not | | | going to be able to do much, Left | | | shift, (more immature cells than | | | mature cells) | | | | | | 2\. Sirs symptoms and a | | | suspected infection. | | | | | | 3\. Severe sepsis: where we | | | start organ damage: altered | | | mentation and increased lactate | | | greater than 2 | | | | | | 4\. Septic shock: sepsis, with | | | severe hypotension, after fluid | | | bolus and no improvement | | | | | | 5\. We want to stay away from | | | \#5 | | | | | | Organisms and their toxins in the | | | bloodstream and entering other | | | body areas, inflammation becomes | | | an enemy, leading to extensive | | | hormonal, tissue, and vascular | | | chances and oxidative stress that | | | further impairs gas exchange and | | | tissue perfusion. | +===================================+===================================+ | If we do not have the adequate | | | resuscitation, then we have | | | sepsis MODS. | | +-----------------------------------+-----------------------------------+ | SIRS Triggers |  | | | | | Sepsis Diagnosis: 2 SIRS criteria | Sirs: trauma, burns, surgery, | | +known or suspected infection | pancreatitis, Sirs is NOT sepsis | | | | | | Sirs must be new to the patient | | | and not part of the treatment | | | | | | MI, injury, microbial invasion, | | | necrotic tissue, surgery, crush | | | injuries, | | | | | | Infection mixes with the SIRS can | | | lead to sepsis. | +-----------------------------------+-----------------------------------+ | **Stress Response** | Physiological Response to Stress | | | | | | Stress→Hypothalamus | | | | | | - Sympathetic NS- | | | norepinephrine | | | | | | - Pituitary- ACTH- | | | Catecholamines, | | | Glucocorticoids | | | | | | Infection creates stress of the | | | body with the physiological | | | response, tachypnea, | | | hypoglycemia, hypothalamus | | | regulates hormones with the | | | anterior pituitary and replases | | | nor epinephrine, | | | | | | Adrenal response releases | | | glucocorticoids- cortisol | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | QSOFA- all the components of | Sepsis 3.0 qSOFA Definition - | | qSOFA are incorporated into the | Diagnostic Criteria - \... \| | | MEWS | GrepMed | | | | | | Q sofa, simple bedside and can | | | take this information and can | | | further check into this and see | | | if we are heading towards sepsis. | | | Different forms of organ | | | dysfunction, | | | | | | Renal failure, hyper bilirubinia, | | | hypovolemia, PE, CHF, | | | | | | Advised that we do not use Q sofa | | | for survival | +===================================+===================================+ | SOFA |  | | | | | ↑ O2 Requirements | | | | | | ↑ Bilirubin | | | | | | ↑ Creatinine | | | | | | ↓ Platelets | | | | | | ↓ Pressure | | | | | | ↓GCS | | | | | | ↓UOP | | +-----------------------------------+-----------------------------------+ | 1. ↑ In Bilirubin | | | | | | 2. ↓ Platelets down | | | | | | 3. ↑O2 requirement up | | | | | | 4. ↓GCS\ | | | | | | - ↑inflammation | | | | | | - ↑ vasodilation | | | | | | - Capillary permeability | | | | | | - Neutrophil and platelet | | | aggregation with adhesion to | | | the endothelium | | | | | | - Faster coagulation | | | | | | - Suppressed fibrinolysis | | | | | | - Hypoperfusion of organs | | | | | | - Cellular ischemia | | | | | | Leaky vascular system, | | | | | | Platelet adhesion, abnormal | | | breakdown of those clots, | | | | | | Proinflammatory factor, | | | vasodilation, | | | | | | Coag happens a little bit faster | | | and hypo | | | | | | Fiber can't break down clots, | | | | | | Lactate increases, anerobic | | | cellular metabolism | +-----------------------------------+-----------------------------------+ | Hypodynamic phase missed due to: | - Short duration | | | | | | - Subtle manifestations | | | | | | - Patient might be afebrile | | | | | | - Pt. might not seek care | | | | | | - If progression of sepsis is | | | stopped at this point, the | | | outcome is likely good | | | | | | Hypo may have a short duration, | | | may be afebrile or might not seek | | | care. If you can stop sepsis in | | | the hypodynamic phase | +-----------------------------------+-----------------------------------+ | Hyperdynamic phase of sepsis is | - Cardiac output increases | | often missed due to: | | | | - SBP increases | | | | | | - Warm extremities | | | | | | - No cyanosis | | | | | | - WBCs are decreasing | | | | | | - Pt. Appears to be better | | | | | | The hyper dynamic phase is missed | | | because the pts. look better and | | | results loos normal, BP, central | | | venous, pressure, skin is | | | flushed, moist, have more | | | immature WBC | +-----------------------------------+-----------------------------------+ | **Severe Sepsis** | Sepsis plus damage in one or more | | | organs = Severe sepsis | | | | | | When you hear severe sepsis and | | | septic shock, you will see the | | | symptoms be the same, | +-----------------------------------+-----------------------------------+ | Tissue **Hypo**perfusion | Sight | | | | | Organ dysfunction | Sensations | | | | | | Taste | | | | | | Sound | | | | | | Smell | | | | | | Decrease response to stimuli, | | | taste, smells, change in the | | | LOC-GCS (good is 15) | | | | | | Edema | | | | | | Slow Pulse | | | | | | MAP\65 (for BP) | | | | | | Arrhythmias | | | | | | Rapid HR | | | | | | Increased capillary =edema | | | | | | CO decrease bp and per pulse | | | | | | Map-mean arterial pressure | | | | | | Dec CO equals dysrhythmia- a fib, | | | MI, infarction, also diminished | | | per. Pulses due to decreased | | | | | | Know what the BP trends are, | +-----------------------------------+-----------------------------------+ | Mean Arterial Pressure | Map= 2xdiastolic Blood Pressure | | | (DBP) + Systolic Blood Pressure | | **(MAP)** | (SBP)/3 (divided by 3) | | | | | | **KNOW HOW to CALCULATE MAP** | +-----------------------------------+-----------------------------------+ | Tissue Hypoperfusion and Organ | **ARDS**- acute respiratory | | Dysfunction | distress syndrome | | | | | | ARDS happens when the lung | | | tissues become inflamed and | | | swollen, making it tough to get | | | enough oxygen. The lungs can also | | | fill with fluid making it harder | | | to breathe | | | | | | Tachypnea \>20 respirations in 1 | | | minute | +-----------------------------------+-----------------------------------+ | Hypoperfusion | GI: leads to ischemia of mucosal | | | lining | | | | | | - Causing ulcers | | | | | | - GI Bleeding | | | | | | - Bacteria in the blood | | | | | | Impaired Liver | | | | | | - Jaundice | | | | | | - ↑ Lactate | | | | | | - ↑ Ammonia | | | | | | Stress response triggers glucose | | | release leading to Hyperglycemia | | | | | | Liver: enzymes, speed up chemical | | | reactions, making bile, clotting | | | factors, things that help break | | | down food and drugs, ALT, AST, | | | | | | Hypoperfusion to the stomach and | | | may lead to developing ulcers, | | | and the issue for the liver to | | | ammonia into the urea ( | | | | | | Liver will throughout more | | | glucose when you are stresses | | | (hyperglycemia), Liver failure | | | you have a high rate for death. | +-----------------------------------+-----------------------------------+ | Hypoperfusi | - **Decreased** urine output | | on | | | of Kidneys | - Prolonged **decreased** blood | | | flow to the kidneys | | | | | | - Elevated Creatinine | | | | | | Hypo perfusion: | | | | | | Leads to Acute tubular ischemia | | | \_low urine out but, inc. | | | BUN/Creat, kidneys not getting | | | enough blood, see the inability | | | to excrete lactic acid and make | | | bicarb. Less than 5 ml/kg per | | | hour | +-----------------------------------+-----------------------------------+ | Hypoperfusion: Hematologic |  | | | | | | DIC- occurs when the formation of | | | the clots of liver, kidneys, | | | brain heart, the collection of | | | clots cause the due to not | | | getting enough of oxygen. | | | | | | Getting the immature WBC, GI | | | tract lungs, puncture site, LOC | | | was gone, | +-----------------------------------+-----------------------------------+ | | - Decreased response to Stimuli | | | | | | - Widespread clotting | | | progressing to bleeding | | | | | | - Decreased Map \