Sepsis - identify and respond

Nurses are expected to be able to recognise and respond to the signs and symptoms of sepsis from the point of registration (Nursing and Midwifery Council (NMC), 2018). This is an important set of skills for nurses to have as sepsis can be fatal in as many as one quarter of cases (Machado and Azevedo, 2018) as well as life changing for survivors.

Sepsis is much more than merely having an infection; it is the body’s response to infection which in turn causes damage to the organs and tissues of the body and suppresses the immune system. One widely used definition of sepsis states that it is:

While septic shock, an important category of sepsis is:

The assessment of a person with suspected sepsis cannot be delayed, it is always considered to be an urgent undertaking. As part of their assessment process, nurses should be familiar with the recording and interpretation of the physiological vital signs as well as how these may vary in different individuals.

As well as being able to undertake vital sign monitoring (covered in another procedure), nurses should also be familiar with other tools for assessing the severity of a patient’s condition such as the National Early Warning Score 2 (NEWS2, covered in the procedure identifying and responding to clinical deterioration).

As in all such situations, nurses assessing and responding to sepsis should not only rely on the objective clinical parameters but should pay attention to what the patient is telling them and what they observe for them self. Where a patient present acutely unwell, one of the differential diagnoses a nurse

The equipment required by the nurse monitoring for sepsis will depend on the situation in which the nurse is working, what monitoring the patient needs and the equipment available to them. To undertake the monitoring required for potential sepsis, the nurse will need:

• a sphygmomanometer
• a thermometer
• a watch or other means of measuring time
• a pulse oximeter
• the means to take bloods
• the means of cleaning/disinfecting equipment between uses
• the patient record
• the appropriate sepsis screening tool for the individual

NICE (2020), identifies a suite of signs and symptoms which may be suggestive of an infection/sepsis:

• identify any recent fever
• identify specific signs or symptoms of infection, e.g. productive cough, dysuria
• signs of dehydration
• presence of confusion
• reduced functional ability
• the presence of comorbidities/medications
• potential for antibiotic resistance, e.g. previous use
• immunisation status

Any of these might prompt the nurse to consider the application of a sepsis screening tool. This procedure applies ‘The Sepsis Screening Tool Acute Assessment for Adults and Children and Young People 12 Years and Over’ (UKST, 2020).

Sepsis screening

The Sepsis Screening Tool Acute Assessment for Adults and Children and Young People 12 Years and Over (UKST, 2020) suggest that sepsis screening should occur if the patient:

• looks unwell
• has a NEWS2 score if 5 or more (see procedure: identifying and responding to clinical deterioration) 

Is it infection?

If the person is unwell, consider the possibility

The main risk from missed, or non-treated sepsis is the death of the individual. Sepsis can also be responsible for the loss of digits or limbs as well as ongoing impacts on the individual’s mental wellbeing (Apitzsch et al, 2021) and therefore early recognition and treatment is important.

Nurses should be familiar with the signs and symptoms of sepsis and be especially alert to how it presents in the people for whom they provide care.

References

Apitzsch S, Larsson L, Larsson AK, Linder A. The physical and mental impact of surviving sepsis - a qualitative study of experiences and perceptions among a Swedish sample. Arch Public Health. 202;79(1):66. https://doi.org/10.1186/s13690-021-00585-5

Bleakley G, Cole M. Recognition and management of sepsis: the nurse's role. British Journal of Nursing. 2020; 29(21): 1248-125. https://doi.org/10.12968/bjon.2020.29.21.1248

Machado F R, Azevedo LCP. Sepsis: A Threat That Needs a Global Solution. Critical Care Medicine. 2018;46(3): 454-459. https://doi.org/10.1097/CCM.0000000000002899

National Institute for Health and Care Excellence. Surgical site infection: Quality Standard 49. 2013 https://www.nice.org.uk/guidance/qs49/resources/surgical-site-infection-2098675107781 (accessed 9 December 2021)

National Institute for Health and Care Excellence: Quality Standard 161. Sepsis. 2017 https://www.nice.org.uk/guidance/qs161/resources/sepsis-pdf-75545595402181 (accessed 9 December 2021)

Nursing and Midwifery Council. Future Nurse: Standards of Proficiency for Registered Nurses. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf (accessed 9 December 2021)

Singer M, Deutschman CS, Seymour CW et al. The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock