Sepsis Recognition for Student Nurses
Learn how to recognise possible sepsis, identify concerning changes, assess the deteriorating patient systematically and escalate concerns promptly as a student nurse.
What is sepsis?
Sepsis is a life-threatening condition that can develop when the body's response to infection causes organ dysfunction. It requires rapid recognition, assessment and treatment.
Infection alone does not automatically mean that a patient has sepsis. The key concern is a patient with suspected or confirmed infection who is becoming clinically unwell, showing signs of deterioration or developing evidence of organ dysfunction.
Student nurses are not expected to diagnose sepsis independently. Your role is to recognise concerning changes, gather appropriate observations, communicate clearly and obtain timely registered clinical support.
Sepsis can begin with many different infections
Sepsis may develop from an infection affecting almost any part of the body. Understanding common sources can help you gather relevant information, but you should avoid becoming so focused on finding the source that escalation is delayed.
Respiratory
Pneumonia and other significant respiratory infections may lead to severe illness and deterioration.
Urinary
Urinary tract and kidney infections can be associated with systemic illness, particularly in vulnerable patients.
Abdominal
Intra-abdominal infection may present with pain, vomiting, abdominal tenderness or more general deterioration.
Skin and wounds
Cellulitis, infected wounds and other skin or soft-tissue infections can sometimes progress significantly.
Devices and procedures
Patients with invasive devices or recent procedures may require particular attention to possible signs of infection.
Unknown source
Sometimes the source of infection is not immediately obvious. Clinical deterioration still requires prompt assessment and escalation.
What might make you suspect sepsis?
Sepsis does not always present in the same way. The patient may have fever, but some patients may have a normal or low temperature. Look at the whole clinical picture rather than relying on one symptom.
Airway and breathing
- Increasing respiratory rate
- New or worsening breathlessness
- Reduced oxygen saturation
- Increased oxygen requirement
- Signs of respiratory distress
Circulation
- Rapid pulse
- Falling blood pressure
- Pale, mottled or clammy skin
- Cool peripheries
- Reduced urine output
Neurological changes
- New confusion
- Drowsiness
- Agitation
- Reduced responsiveness
- Sudden change from normal behaviour
Other concerning signs
- High or low temperature
- Rigors or feeling very cold
- Severe weakness
- New severe pain
- Evidence of infection or rapidly worsening illness
Some patients may be more vulnerable to severe infection
Clinical context matters. Certain patients may have a greater risk of developing serious infection or may present atypically.
- Older adults
- Very young patients
- People who are immunosuppressed
- Patients receiving chemotherapy or other immunosuppressive treatment
- People with significant long-term conditions
- Patients who have recently undergone surgery or invasive procedures
- People with indwelling devices or catheters
- Patients who are pregnant or recently postpartum
Use ABCDE when the patient appears acutely unwell
The ABCDE approach helps you assess deterioration systematically and prioritise the most immediate threats to life.
Airway
Check whether the airway is patent and look for any evidence of obstruction. Escalate immediately if airway compromise is suspected.
Breathing
Assess respiratory rate, oxygen saturation, work of breathing and other relevant respiratory signs within your competence.
Circulation
Consider pulse, blood pressure, perfusion, skin appearance and urine output where appropriate.
Disability
Assess conscious level and look for new confusion, drowsiness or reduced responsiveness.
Exposure
Look for possible sources or signs of infection, such as wounds, rashes, swelling or other relevant findings, while maintaining dignity and privacy.
Use NEWS2 to support recognition of deterioration
NEWS2 is widely used across NHS services to help identify patients whose physiological observations indicate increasing clinical risk.
In a patient with suspected infection, changes in respiratory rate, oxygen saturation, blood pressure, pulse, consciousness and temperature can contribute to recognising significant deterioration.
What should you do if you suspect sepsis?
Recognise the deterioration
Identify changes in observations, behaviour, symptoms or general clinical appearance.
Call for registered help
Inform the registered nurse, practice supervisor or another appropriate clinician promptly.
State that you are concerned about possible sepsis
Clear language helps communicate urgency. Explain the suspected infection, relevant observations and what has changed.
Use local pathways
Follow your NHS trust, health board or placement provider's local sepsis screening, deterioration and escalation process.
Continue reassessment
Patient condition can change quickly. Repeat observations and report any further deterioration.
Use SBAR to make your concern clear
Example scenario
A patient being treated for a urinary infection becomes newly confused. Their respiratory rate has risen to 28, pulse is 118 and blood pressure has fallen compared with earlier observations.
You do not need to independently diagnose sepsis before escalating. The important action is recognising deterioration and communicating your concern promptly.
What happens after sepsis is suspected?
Once a patient is identified as being at risk of sepsis, registered clinicians will assess the patient and follow current local and national guidance. This may involve urgent investigations, monitoring and treatment.
Depending on the patient's condition and local protocol, the wider clinical team may consider actions such as obtaining blood tests and cultures, administering prescribed antimicrobial treatment, managing oxygenation and circulation, and monitoring urine output and response to treatment.
Common mistakes that can delay escalation
Waiting for a high temperature
Serious infection can occur without marked fever. Look at the whole clinical picture.
Waiting for certainty
Students do not need to confirm the diagnosis before raising a concern.
Focusing on one observation
Trends and combinations of changes are often more important than one isolated measurement.
Assuming confusion is normal
New confusion should always be taken seriously and assessed in the wider clinical context.
Relying only on NEWS2
A score is a support tool. Clinical deterioration may still require urgent escalation.
Being afraid to speak up
Patient safety takes priority. If you remain concerned, raise the concern again through the appropriate pathway.
Record observations and escalation accurately
Accurate documentation supports communication and continuity of care. Record information according to your organisation's documentation policy and your level of responsibility.
- Record physiological observations accurately.
- Document relevant changes in the patient's condition.
- Record escalation and subsequent actions where required.
- Use objective clinical information rather than assumptions.
- Seek supervision if you are unsure what should be documented.
Sepsis recognition checklist for students
- Is there known or suspected infection?
- Has the patient's respiratory rate increased?
- Has oxygen saturation fallen or oxygen requirement increased?
- Is the pulse becoming unusually fast or slow?
- Has blood pressure fallen?
- Is the patient newly confused, drowsy or less responsive?
- Has urine output reduced?
- Does the patient appear pale, clammy, mottled or significantly more unwell?
- Has NEWS2 increased?
- Have I escalated my concern to an appropriate registered practitioner?
Your role as a student nurse
The NMC Code emphasises prioritising people, preserving safety, communicating effectively and acting without delay when there is a risk to patient safety.
In practice, this means student nurses should develop the confidence to recognise concerning changes, report them clearly and seek help promptly while remaining within their competence and supervision arrangements.
Key takeaway
Sepsis recognition begins with noticing deterioration in a patient who may have an infection. Look for changes in breathing, circulation, conscious level, temperature, urine output and overall clinical appearance.
Use ABCDE and NEWS2 appropriately, communicate concerns clearly and escalate promptly. You do not need to independently diagnose sepsis before asking for help.
Always work within your scope of practice and competence, follow your organisation's local sepsis and escalation policies, and seek appropriate supervision from registered practitioners.
