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Module 3.1: Assessment
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Assessment and Examination

Suspect sepsis in any person presenting with:

  • Symptoms or signs indicating possible infection causing significant illness or deterioration. This includes people who are deteriorating unexpectedly or failing to improve as expected.
  • One or more risk factor(s) for sepsis and who looks unwell.
  • Concern from a relative or carer that there is a change in appearance or behaviour.

Be aware that:

  • People with sepsis may present with non-specific, non-localised clinical features, for example, general malaise, agitation or behavioural change.
  • People with sepsis may not present with a high temperature and may present with hypothermia.
  • Sepsis may result from infection with almost any pathogen; therefore, it may present with a wide range of clinical features depending on the site of infection and host response. The most common sites of infection leading to sepsis are the respiratory, gastrointestinal, renal and genitourinary tracts, as well as blood, skin, soft tissue, bone and joint sources.

Patient Assessment

Ask the person/carers about:

  • Any recent fever or rigors.
  • Any symptoms suggesting specific infection, such as dysuria or productive cough.
  • Clinical features suggesting dehydration, such as reduced urine output in the past 18 hours.
  • Any altered behaviour, mental state, or cognition, such as not responding normally to social cues or waking only with prolonged stimulation or new irritability (in children); new-onset confusion (in adults). See the CKS topic on Delirium for more information.
  • Any sudden change or deterioration in functional ability.
  • Possible risk factors for sepsis, including co-morbidities and drug treatments.
  • Possible risk factors for antibiotic resistance, such as recent or previous antibiotic therapy, previous hospital admissions and residency in a care home
  • Immunisation status (particularly in infants and young children).

(NICE, 2020)

Face to Face

Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis. Measure oxygen saturation (in community settings, if equipment is available and taking a measurement does not cause a delay in assessment or treatment).

In suspected sepsis, examine for mottled or ashen appearance, cyanosis of the skin, lips or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection.

Ask about the frequency of urination in the past 18 hours.