Nursing Sepsis Recognition and Response

Create a sepsis recognition and response documentation for patient showing signs of infection.

Patient details:
- Suspected source of infection: [describe]
- SIRS criteria present: [list which]
- NEWS or qSOFA score: [number]
- Risk factors: [immunocompromised/age/comorbidities]

SEPSIS SCREENING AND RESPONSE

1. RECOGNITION — SIRS CRITERIA
   - Temperature: [above 38C or below 36C]
   - Heart rate: [above 90 bpm]
   - Respiratory rate: [above 20 or PaCO2 below 32]
   - WBC: [above 12,000 or below 4,000]
   - Number of criteria met: [2 or more = SIRS]

2. SEPSIS ALERT TRIGGERED
   - Time alert triggered: [time]
   - Physician notified: [time]
   - Sepsis protocol activated: [yes/no]

3. SEPSIS BUNDLE — HOUR 1
   - Blood cultures obtained: [time — before antibiotics]
   - Number of sets: [2 — from 2 sites]
   - Lactate drawn: [time and result]
   - Broad spectrum antibiotics started: [drug/dose/time]
   - IV fluid bolus: [30 mL/kg — amount and time started]
   - Vasopressors: [if MAP below 65 despite fluids]

4. REASSESSMENT AT 3 HOURS
   - Fluid resuscitation status: [mL given]
   - MAP: [target above 65]
   - Urine output: [target 0.5 mL/kg/hr]
   - Lactate recheck: [if initial above 2]
   - Clinical response: [improving/worsening]

5. ONGOING MONITORING
   - Vital signs: [frequency]
   - Mental status changes: [note]
   - Organ dysfunction signs: [monitor]
   - Culture results: [pending/resulted]
   - Antibiotic appropriateness: [review at 72 hours]

Note: Placeholder information only — follow institutional sepsis protocols