Sepsis Recognition and Nursing Priorities

Responding to suspected sepsis

These priorities apply to adult care. They support, but do not replace, clinical judgment, provider orders, or facility protocols. Current adult guidance recommends immediate treatment and resuscitation when sepsis or septic shock is suspected.

Recognizing SIRS

SIRS describes a systemic inflammatory pattern; it is not synonymous with sepsis. It is present when at least two of the following criteria occur:

• Temperature greater than $38^\circ\text{C}$ or less than $36^\circ\text{C}$.

• Heart rate greater than $90/\text{min}$.

• Respiratory rate greater than $20/\text{min}$, or PaCO₂ less than $32\ \text{mm Hg}$.

• White blood cell count greater than $12{,}000/\text{mm}^3$, less than $4{,}000/\text{mm}^3$, or greater than $10\%$ immature bands.

SIRS can have infectious or noninfectious causes. Meeting its criteria does not by itself establish sepsis or septic shock. For example, a patient with a temperature of $39.1^\circ\text{C}$, heart rate of $108/\text{min}$, respiratory rate of $24/\text{min}$, and WBC count of $8{,}000/\text{mm}^3$ meets SIRS criteria despite a normal WBC count.

Using screening criteria

SIRS and qSOFA can support recognition, but neither alone diagnoses or excludes sepsis. qSOFA uses these bedside risk indicators:

• Respiratory rate at least $22/\text{min}$.

• Altered mentation.

• Systolic blood pressure at most $100\ \text{mm Hg}$.

A negative qSOFA score does not rule out sepsis, and two SIRS criteria do not prove sepsis. Current adult guidance recommends using tools such as NEWS/NEWS2, MEWS, or SIRS rather than qSOFA alone for in-hospital screening. Screening scores should not delay evaluation or treatment.

Recognizing organ dysfunction

Suspected infection accompanied by new organ dysfunction or poor perfusion is an emergency. New confusion, low blood pressure, and falling urine output in a patient being treated for a urinary infection are concerning findings. Promptly alert the responsible clinician or activate the facility's response pathway while assessing and supporting airway, breathing, and circulation.

Do not wait for culture confirmation to escalate care. Sepsis is a clinical diagnosis and should not be ruled in or out by one test or screening score.

Interpreting laboratory findings

Interpret laboratory findings together with the patient's clinical condition. Elevated lactate can signal impaired tissue perfusion, but it is not specific to sepsis or a particular organism. Rising creatinine, thrombocytopenia, and bilirubin above the reference range may indicate organ dysfunction. For example, lactate of $4.2\ \text{mmol/L}$, creatinine increased from baseline, platelets of $88{,}000/\text{mm}^3$, and elevated bilirubin in a patient with suspected infection require prompt clinical evaluation.

Cultures help identify pathogens, but a positive blood culture is not required to recognize or treat sepsis. No single laboratory result establishes or excludes sepsis.

Identifying septic shock

Sepsis-3 describes septic shock as sepsis with persistent hypotension that requires vasopressors to maintain MAP at least $65\ \text{mm Hg}$, and lactate greater than $2\ \text{mmol/L}$, despite adequate volume resuscitation. These criteria describe a clinical construct: receiving fluids does not exclude septic shock, and lactate above $2\ \text{mmol/L}$ alone does not establish it.

Coordinating cultures and antimicrobials

For probable sepsis with shock, collect ordered blood cultures promptly before antimicrobials when possible, provided collection will not cause a clinically significant treatment delay. Expedite prescribed antimicrobial therapy rather than waiting for culture results or for a fever to develop.

For possible, probable, or definite septic shock, current adult guidance recommends immediate antimicrobial therapy, ideally within $1$ hour of recognition.

Individualizing fluid resuscitation

For adults with sepsis-induced hypoperfusion or septic shock, current guidance suggests at least $30\ \text{mL/kg}$ of IV crystalloid within the first $3$ hours. For a patient weighing $70\ \text{kg}$, this suggested amount is $2{,}100\ \text{mL}$.

This is not an automatic bolus for every patient with suspected sepsis. Consider individual circumstances, monitor frequently, and reassess to avoid both under-resuscitation and fluid overload. Do not withhold fluids solely until a central venous catheter is placed.

Reassessing response to fluids

After an initial fluid bolus, reassess hemodynamics and clinical perfusion, and report the findings. Include blood pressure and MAP, mental status, capillary refill, and urine output. Also assess lung sounds, oxygenation, and work of breathing for respiratory deterioration or signs of fluid overload.

Serial lactate may help guide resuscitation, but fluids should be individualized rather than continued solely until lactate normalizes. Reassessment involves more than checking temperature alone.

Managing persistent hypotension

For adults with septic shock, norepinephrine is the recommended first-line vasopressor, with an initial MAP target of about $65\ \text{mm Hg}$. Guidance supports starting vasopressors peripherally rather than delaying treatment solely to obtain central access. Follow facility policy and monitor closely.

If hypotension persists after initial fluid resuscitation, anticipate vasopressor support. Continue to reassess the patient rather than giving fluids without reassessment until blood pressure normalizes.