A nurse is performing a focused assessment on a 72-year-old client with suspected sepsis from a urinary source. Identify all findings consistent with sepsis or septic shock that require immediate provider notification. Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Sepsis criteria (Sepsis-3): suspected infection plus acute change in SOFA 2 or more. Septic shock: persistent hypotension requiring vasopressors plus lactate above 2 despite fluid resuscitation. qSOFA bedside: RR 22 or more, altered mental status, SBP 100 or less. Findings consistent: (1) HR 122 — sustained tachycardia, (2) MAP 58 mm Hg — under perfusion threshold of 65, (4) T 38.9 with rigors — infection signal, (6) RR 26 with increased effort — qSOFA positive, (8) lactate 4.1 — tissue hypoperfusion. Cap refill 2 s (3) is normal. Warm dry skin (5) and SpO2 98 percent (9) are reassuring not concerning. Strong hand grasps (10) is normal neuro.
Findings — Concerning 1. HR 122/min — sustained tachycardia from compensated shock 2. MAP 58 mm Hg — below 65 perfusion target 3. T 38.9 plus rigors — infection signal 4. RR 26 with effort — qSOFA positive 5. Lactate 4.1 — tissue hypoperfusion
Findings — Reassuring - Cap refill 2 s (normal under 3) - Skin warm dry (early sepsis can show this) - SpO2 98 percent room air - Bowel sounds, hand grasps normal
Action Notify provider, initiate Hour-1 bundle.
NCSBN Theme PA — Medical emergency / sepsis recognition.
Scenario72-year-old, suspected sepsis from urinary source.
Findings to Sort10 assessment findings — identify those consistent with sepsis or septic shock.
Sepsis-3 + qSOFA- qSOFA positive: 2 or more of (RR 22+, altered LOC, SBP 100-)- Septic shock: vasopressor plus lactate over 2 despite fluids
Sepsis-3 / qSOFA — Sepsis: suspected infection plus acute change in SOFA 2 or more. Septic shock: persistent hypotension on vasopressors plus lactate above 2 mmol/L despite adequate fluid resuscitation. qSOFA quick bedside screen: RR 22 or more, altered mental status, SBP 100 or less — 2 of 3 suggests sepsis with poor outcome.
Lactate as a perfusion marker — Serum lactate above 2 mmol/L suggests tissue hypoperfusion; above 4 mmol/L is associated with significantly higher mortality. Used in Surviving Sepsis Hour-1 bundle as both diagnostic and reperfusion target — repeat at 2 to 4 hours to assess response. Other causes of elevated lactate: shock of any type, severe exercise, metformin toxicity, propofol infusion syndrome.
Surviving Sepsis Hour-1 bundle — (1) Measure lactate; (2) Blood cultures before antibiotics; (3) Broad-spectrum IV antibiotics; (4) 30 mL/kg crystalloid for hypotension or lactate above 4; (5) Vasopressor (norepinephrine first-line) if MAP under 65 after fluid. All initiated within 1 hour of recognition.