Chart — Emergency Nursing
Sepsis Recognition Chart
Quick-reference sepsis recognition chart — SIRS, qSOFA, organ dysfunction (SOFA), lactate thresholds, septic shock criteria, escalation triggers, and nursing actions for early identification and response.
Educational use only. This content is intended for nursing students and exam preparation. Clinical decisions require licensed professional judgment and institutional protocols. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
qSOFA Score — Bedside Screening Tool
qSOFA (quick SOFA) ≥2 points = high risk for poor outcomes from sepsis. Score 1 point for each of the following:
Altered mental status
Any change in mental status from baseline — new confusion, agitation, somnolence, or GCS reduction
Respiratory rate ≥22/min
Tachypnea — respiratory compensation for metabolic acidosis or sepsis-related lung injury
Systolic BP ≤100 mmHg
Hypotension — vasodilation from systemic inflammatory response overwhelming compensatory mechanisms
0–1 pts
Low Risk
Does not meet high-risk threshold — reassess if clinical picture changes
2 pts
High Risk
Likely sepsis — initiate sepsis protocol, notify provider, obtain full SOFA assessment
3 pts
Critical
All three criteria met — highest risk; immediate sepsis workup and aggressive resuscitation
Sepsis Recognition: Key Findings
| Finding | Category | Significance | Escalation Trigger | Nursing Action |
|---|---|---|---|---|
| Fever or Hypothermia | SIRS | SIRS criterion #1 — systemic inflammatory response to infection | Temp >38.3°C (100.9°F) or <36°C (96.8°F) with suspected infection source | Obtain blood cultures ×2 before antibiotics; assess infection source; initiate sepsis screening protocol |
| Tachycardia | SIRS | SIRS criterion #2 — sympathetic activation compensating for vasodilation | HR >90 bpm in context of fever or suspected infection | Apply cardiac monitor; 12-lead ECG if HR >130; IV access ×2; alert provider |
| Tachypnea | SIRS + qSOFA | SIRS criterion #3 AND qSOFA criterion — respiratory compensation for metabolic acidosis; also direct sign of sepsis-related lung injury | RR >20 breaths/min AND/OR PaCO₂ <32 mmHg | Apply supplemental oxygen; continuous SpO₂; assess work of breathing; ABG if SpO₂ <92% |
| Altered Mental Status | qSOFA | qSOFA criterion — cerebral hypoperfusion or direct CNS effect of sepsis; prognostic sign of severity | Any new confusion, agitation, or decreased GCS from baseline — especially with infection signs | GCS assessment; fall precautions; neuro checks every 15 min; notify provider immediately — this is a high-risk sign |
| Hypotension | qSOFA + Septic Shock | qSOFA criterion + septic shock indicator — vasodilation overwhelms compensatory mechanisms | SBP <100 mmHg (qSOFA) or vasopressor requirement to maintain MAP ≥65 mmHg after adequate fluid resuscitation (Sepsis-3 septic shock criterion) | 30 mL/kg IV crystalloid STAT; norepinephrine if refractory; continuous BP monitoring; notify provider STAT |
| Leukocytosis or Leukopenia | SIRS | SIRS criterion #4 — elevated WBC (>12,000) indicates immune response; suppressed WBC (<4,000) or >10% bands indicates overwhelming infection or immunosuppression | WBC >12,000/mm³ or <4,000/mm³ or >10% immature bands | Obtain CBC with differential; monitor trend; blood cultures before antibiotics; report critical values per policy |
| Elevated Lactate | Organ Dysfunction | Tissue hypoperfusion marker — elevated lactate indicates cells are switching to anaerobic metabolism due to inadequate oxygen delivery | Lactate ≥2 mmol/L = tissue hypoperfusion; lactate ≥4 mmol/L = severe hypoperfusion + sepsis-bundle trigger for 30 mL/kg crystalloid (NOT itself a septic shock criterion — shock also requires a vasopressor need to maintain MAP ≥65 after fluid resuscitation) | Repeat lactate in 2 hours after resuscitation; target lactate clearance ≥10% with treatment; STAT provider notification for lactate ≥4 |
| Oliguria / Renal Dysfunction | Organ Dysfunction | SOFA criterion — renal hypoperfusion; urine output <0.5 mL/kg/hr for ≥2 hours indicates organ dysfunction | Urine output <0.5 mL/kg/hr for 2+ hours OR creatinine >1.2 mg/dL (new elevation) | Strict I&O with hourly measurements; Foley catheter if not present; adequate fluid resuscitation before diuretics; notify provider |
| Coagulopathy / Thrombocytopenia | Organ Dysfunction | SOFA criterion — disseminated intravascular coagulation (DIC) risk; platelet count falling with sepsis = end-organ involvement | Platelets <100,000/mm³ (new) or INR >1.5 in sepsis context | Monitor for bleeding at IV sites and mucous membranes; avoid unnecessary sticks; report critical coag values; prepare for possible FFP/platelet transfusion |
| Hyperbilirubinemia | Organ Dysfunction | SOFA criterion — hepatic dysfunction from sepsis-related decreased liver perfusion | Total bilirubin >2 mg/dL (new elevation) | Monitor LFT trend; assess for jaundice; hepatotoxic medication review; notify provider |
| Vasopressor Requirement | Septic Shock | Septic shock diagnostic criterion — distributive shock so severe that vasopressors are needed to maintain MAP ≥65 mmHg after adequate resuscitation | MAP <65 mmHg despite ≥30 mL/kg crystalloid resuscitation | Norepinephrine first-line via central access (peripheral acceptable as bridge); arterial line for continuous BP monitoring; ICU transfer |
Sepsis Bundle — Time-Based Actions
Measure lactate; blood cultures ×2 before antibiotics; broad-spectrum IV antibiotics STAT; 30 mL/kg IV crystalloid if hypotensive or lactate ≥4 mmol/L
Re-assess volume status; vasopressors if MAP <65 mmHg after resuscitation; repeat lactate if initial ≥2 mmol/L
Target MAP ≥65 mmHg; urine output ≥0.5 mL/kg/hr; lactate clearance ≥10%; reassess fluid responsiveness
Septic Shock — Diagnosis Criteria (Sepsis-3)
Septic shock = sepsis PLUS: (1) vasopressor required to maintain MAP ≥65 mmHg AND (2) serum lactate >2 mmol/L, despite adequate fluid resuscitation. Mortality >40%. ICU admission required.
Source: Singer M, et al. JAMA. 2016; Sepsis-3 Definitions. Surviving Sepsis Campaign Guidelines 2021.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Singer M, et al. JAMA. 2016 (Sepsis-3); Surviving Sepsis Campaign Guidelines 2021. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →