[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Critical care](https://durgical.com/en/nursing/areas/critical-care/) › Sepsis and septic shock: screening, the first-hour bundle from the nursing side and watching organ dysfunction # Sepsis and septic shock: screening, the first-hour bundle from the nursing side and watching organ dysfunction - Safe practice Nurses screen for sepsis, raise the alarm and deliver the first-hour actions: lactate, cultures, antimicrobial, fluids and pressure support. Updated Nov 13, 2026 ## Key points - Screen every patient with a suspected infection with the institution's tool; qSOFA should not be used alone as the screening tool. - Septic shock or probable sepsis: antimicrobials immediately, ideally within 1 hour of recognition. - Blood cultures before the antimicrobial, but do not delay the antimicrobial for them (the guideline accepts under 45 minutes). - Measure lactate; if it is high, repeat it to guide resuscitation. - Fluid for hypoperfusion: a crystalloid volume per kilogram of body weight within the first 3 hours, as ordered; vasopressors if MAP stays below 65 mmHg. ## What it is Sepsis is an emergency, and every hour of delay matters. Nurses are often the first to notice it: a patient with an infection whose heart rate and breathing rise, whose temperature is high or low, who becomes confused or whose blood pressure falls. The nurse screens with the institution's tool, calls the team at once and starts the sepsis protocol. In the first hour the nurse draws lactate and blood cultures, gives the first antimicrobial as soon as it is ordered, gives the fluid ordered for hypoperfusion and watches the response, and prepares for vasopressors if the pressure stays low. After that, the nurse watches each organ (brain, lungs, kidneys, skin and perfusion) and reassesses often. This is the only DurgiPedia nursing page on sepsis; it covers the ward and the ICU. ## What it requires - A screening tool the whole unit uses (for example an early-warning score or SIRS criteria) and a sepsis protocol everyone knows. - Quick access to cultures, lactate and the first antimicrobial dose, and a clear person to call. - Standing orders or a protocol that lets the nurse start the first actions without waiting. - Admission to intensive care within 6 hours for patients who need it, as the guideline suggests. ## Components - Recognise: infection plus warning signs (temperature over 38 °C or under 36 °C, heart rate over 90, breathing over 20, new confusion, low blood pressure). - Act within the first hour: lactate, blood cultures, antimicrobial, fluid for hypoperfusion, vasopressor if pressure stays low. - Reassess: response to fluid, lactate trend, capillary refill, urine output and organ function. - Source control and review: help the team find and remove the source, including an infected line. ## How it is applied (and why) - Screen each patient with suspected infection at each set of vital signs — sepsis often starts with small changes. - If the screen is positive, call the doctor or rapid response team at once and start the protocol — every hour of delay worsens survival. - Give oxygen as ordered, place IV access and start continuous monitoring — the patient can deteriorate fast. - Draw lactate and blood cultures from different sites, as the protocol says, before the antimicrobial if it causes no real delay — cultures guide treatment. - Give the first antimicrobial as soon as it is ordered and record the time — in septic shock the goal is within 1 hour. - Give the fluid ordered for hypoperfusion: a volume per kilogram, so the total is that amount times the patient's weight — then reassess after each part. - Reassess pressure, heart rate, capillary refill, breathing, lung sounds and urine output — stop and report if overload signs appear. - If MAP stays below the goal, prepare the vasopressor; it can start in a good peripheral vein while a central line is placed — waiting harms perfusion. - Repeat the lactate as ordered when the first was high — a falling lactate shows the resuscitation is working. - Report a line or wound that may be the source and help with cultures from it — the source must be controlled quickly. ## In nursing practice - Older adults may show new confusion or lethargy instead of fever, and a very severe infection can lower the white cell count. - Watch each organ: new confusion, faster breathing or a greater need for oxygen, falling urine output and mottled skin. - A capillary refill time is a simple bedside guide that the guideline suggests using alongside other measures. - Once the cause is known, the team narrows or stops the antimicrobials; remind them of the review time the protocol sets. ## Common mistakes - Waiting for a low blood pressure before suspecting sepsis. - Delaying the antimicrobial to obtain cultures. - Giving fluid without checking the response and the lungs after each part. - Not recording the times of recognition, cultures, antimicrobial and fluid, which the team needs to review the bundle. - Relying on a single screening score. ## Test yourself Think of the answer, then tap the question to see it. ## Within what time should an antimicrobial be given in septic shock? Immediately, ideally within 1 hour of recognising septic shock or probable sepsis. ## Should blood cultures be drawn before the antimicrobial? Yes, as long as it does not cause a substantial delay; the antimicrobial is not held back to obtain them. ## Which warning signs suggest sepsis in a patient with an infection? Temperature over 38 °C or under 36 °C, heart rate over 90, breathing over 20, new confusion and low blood pressure. ## How is the fluid volume for sepsis-induced hypoperfusion worked out? It is a volume per kilogram of body weight set by the guideline and the order, multiplied by the patient's weight, given within the first 3 hours and reassessed often. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/sepsis-and-septic-shock-screening-the-first-hour-bundle-from-the-nursing-side-an/) ## Elsewhere in DurgiPedia - [Fever, infection and sepsis: the bedside signs](https://durgical.com/en/clinical-exam/fever-infection-and-sepsis-the-bedside-signs/) ## Connections ## Related 4 - [Nursing the patient in shock: early signs, monitoring, fluid challenge and fluid overload, positioning, by type of shock](https://durgical.com/en/nursing/nursing-the-patient-in-shock-early-signs-monitoring-fluid-challenge-and-fluid-ov/) - [Blood cultures: technique that avoids contamination](https://durgical.com/en/nursing/blood-cultures-technique-that-avoids-contamination/) - [Preventing healthcare-associated infections: the care bundles](https://durgical.com/en/nursing/preventing-healthcare-associated-infections-the-care-bundles/) - [Recognising deterioration and calling the rapid response team](https://durgical.com/en/nursing/recognising-deterioration-and-calling-the-rapid-response-team/) ## Related conditions 1 - [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/) [← All of nursing](https://durgical.com/en/nursing/) Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order. Sources: [Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021 (Evans L et al., Intensive Care Med 2021;47:1181-1247)](https://pmc.ncbi.nlm.nih.gov/articles/PMC8486643/) (Society of Critical Care Medicine and European Society of Intensive Care Medicine, open access in PubMed Central, 2021); [Nursing Fundamentals, 9.7 Applying the Nursing Process (infection)](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/09:_Infection/9.07:_Applying_the_Nursing_Process) (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); [Caring for Patients with Sepsis](https://www.cdc.gov/sepsis/hcp/clinical-care/index.html) (Centers for Disease Control and Prevention (CDC), 2025). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/sepsis-and-septic-shock-screening-the-first-hour-bundle-from-the-nursing-side-an/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/sepsis-and-septic-shock-screening-the-first-hour-bundle-from-the-nursing-side-an/