Sepsis Nursing Guide 2026: Sepsis-3, Bundles, and Shock Management

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Contents: Sepsis-3 Definition qSOFA and SOFA 1-Hour Bundle Fluid Resuscitation Vasopressors Nursing Monitoring Common Sources NCLEX High-Yield

Sepsis-3 Definitions (2016)

Term	Sepsis-3 Definition	Key Concept
Sepsis	Life-threatening organ dysfunction caused by a dysregulated host response to infection	Infection + organ dysfunction (SOFA score increase ≥2 from baseline)
Septic Shock	Subset of sepsis with circulatory, cellular, and metabolic abnormalities that substantially increase mortality	Sepsis + need for vasopressors to maintain MAP ≥65 AND lactate >2 mmol/L despite adequate fluid resuscitation
SIRS (old criteria)	No longer in Sepsis-3 definition; may still be used in some facilities	2+ of: temp >38 or <36; HR >90; RR >20 or PaCO2 <32; WBC >12K or <4K or >10% bands

Sepsis-3 replaced SIRS criteria because SIRS was overly sensitive (captures many non-septic patients). The focus shifted to organ dysfunction as the hallmark of sepsis severity.

Assessment Criteria: qSOFA and SOFA

qSOFA (Quick SOFA — Bedside Screening)

For rapid bedside identification of patients outside the ICU with suspected infection who are at risk for poor outcomes (each criterion = 1 point):

Altered mental status (GCS <15)
RR ≥22 breaths/min
Systolic BP ≤100 mmHg

qSOFA ≥2 points = high risk for poor outcome; consider ICU-level care, full SOFA assessment, and sepsis workup. qSOFA is a SCREENING tool, not diagnostic.

SOFA Score (Sequential Organ Failure Assessment)

System	Variable Assessed
Respiratory	PaO2/FiO2 ratio
Coagulation	Platelet count
Liver	Bilirubin
Cardiovascular	MAP or vasopressor requirement
CNS	Glasgow Coma Scale (GCS)
Renal	Creatinine or urine output

SOFA increase of ≥2 from baseline = organ dysfunction = sepsis. Score 0–24; higher = worse outcomes.

Surviving Sepsis 1-Hour Bundle (2018)

The Surviving Sepsis Campaign 2018 moved from 3-hour and 6-hour bundles to a SINGLE 1-HOUR bundle — measure, resuscitate, and start antibiotics all within the first hour.

Element	Action Within 1 Hour
1. Measure lactate	Serum lactate; repeat lactate in 2 hr if initial >2 mmol/L
2. Obtain blood cultures	At least 2 sets of blood cultures (aerobic + anaerobic) from 2 different sites BEFORE antibiotics if can be done without delaying antibiotics more than 45 min
3. Broad-spectrum antibiotics	Start empiric broad-spectrum IV antibiotics; every hour of delay increases mortality 7%; do NOT wait for culture results
4. IV fluid resuscitation	30 mL/kg crystalloid (NS or LR) for hypotension (MAP <65) OR lactate ≥4 mmol/L; give as bolus, not slow infusion
5. Vasopressors	Norepinephrine first-line if hypotension persists after fluid; target MAP ≥65 mmHg

Antibiotic timing is critical. Every 1-hour delay in antibiotics increases sepsis mortality by ~7%. Draw blood cultures first if rapid, but do NOT delay antibiotics waiting for cultures.

Fluid Resuscitation in Sepsis

Initial: 30 mL/kg IV crystalloid within 3 hr (LR preferred over NS — large NS volumes cause hyperchloremic metabolic acidosis)
Reassess fluid responsiveness frequently: improvement in MAP, HR, urine output, lactate clearance, CVP
After initial resuscitation: give fluids ONLY if patient is fluid-responsive (passive leg raise test: elevate legs 45 degrees x 1 min — if SBP or CO increases by ≥10%, patient is fluid-responsive)
Avoid indiscriminate fluid administration — fluid overload worsens ARDS, AKI, and outcomes
Target endpoints: MAP ≥65; urine output ≥0.5 mL/kg/hr; lactate clearance ≥10% per 2 hr; ScvO2 ≥70%

Lactate Interpretation

Lactate Level	Interpretation	Action
<2 mmol/L	Normal; adequate tissue perfusion	Continue monitoring
2–4 mmol/L	Elevated; suggests increased anaerobic metabolism; risk stratification	Aggressive resuscitation; repeat lactate in 2 hr to assess clearance; consider ICU
>4 mmol/L	Severe; high mortality risk; tissue oxygen debt; immediate action required	Septic shock = vasopressors, ICU, aggressive resuscitation; repeat lactate q2h

Vasopressors in Septic Shock

Agent	First-Line?	Mechanism	Dose / Notes
Norepinephrine (Levophed)	YES — first-line	Alpha-1 > beta-1; vasoconstriction + modest inotropy	0.01–3 mcg/kg/min IV; central line preferred (peripheral for short term only); mix in D5W; extravasation = tissue necrosis (phentolamine antidote)
Vasopressin	Second-line (added to norepinephrine)	V1 receptor vasoconstriction; "norepinephrine-sparing"; does NOT increase with dose	Fixed dose 0.03–0.04 units/min; do NOT titrate; preserves renal blood flow
Epinephrine	Third-line or cardiac arrest	Alpha + beta (strong); inotropy + chronotropy + vasoconstriction	Added when norepinephrine + vasopressin insufficient; increases lactate (metabolic effect)
Dopamine	Alternative to norepinephrine in bradycardic patients	Dose-dependent: low = renal vasodilation (no longer recommended to protect kidneys); mid = cardiac; high = vasoconstriction	More arrhythmias than norepinephrine; generally avoided in septic shock unless refractory bradycardia
Dobutamine	Added for low cardiac output despite adequate MAP	Beta-1 > beta-2; pure inotrope; increases CO; also causes vasodilation (may drop BP)	2.5–20 mcg/kg/min; for cardiogenic component; watch for tachycardia

Vasopressor Nursing Priorities

Central line preferred for all vasopressors; peripheral IV acceptable for short-term initiation
Dedicated IV lumen for vasopressors; do NOT co-infuse with incompatible fluids
Continuous arterial line for accurate MAP monitoring
Assess infusion site hourly for extravasation (especially norepinephrine — tissue necrosis)
Document dose (mcg/kg/min), MAP target, and response every hour
NEVER abruptly discontinue vasopressors — taper gradually as tolerated

Ongoing Sepsis Nursing Monitoring

Parameter	Frequency	Target
Vital signs (HR, BP, RR, Temp, SpO2)	Continuous or q15min during resuscitation; q1h when stable	MAP ≥65; HR <110; RR <30; temp trending toward normal; SpO2 ≥92%
Urine output	Hourly	≥0.5 mL/kg/hr (≥30 mL/hr)
Lactate	Repeat 2–6 hr after initial	Clearance ≥10% per 2 hr; target <2 mmol/L
Mental status	q1–2 hr	Improving GCS; resolving encephalopathy
Skin and perfusion	q1–2 hr	Improving capillary refill (<3 sec); warm extremities; decreasing mottling
Labs (BMP, CBC, coags)	q6–12 hr as indicated	Trending electrolytes, creatinine, bilirubin, platelet count

Common Sources of Sepsis

Mnemonic LUMP-UR:

L — Lungs (pneumonia — most common source)
U — Urinary tract (UTI, pyelonephritis — most common in elderly women)
M — Meninges (meningitis)
P — Peritoneum (intra-abdominal, peritonitis, cholangitis)
U — Unknown (10–20% no source found)
R — Resistant (MRSA, gram-negatives — wound, line infections)

NCLEX High-Yield Points

Sepsis-3: infection + organ dysfunction (SOFA ≥2). Septic shock: sepsis + vasopressors needed + lactate >2
qSOFA ≥2: altered mental status, RR ≥22, SBP ≤100 = high sepsis risk
1-Hour Bundle: lactate + blood cultures + antibiotics + 30 mL/kg fluids + vasopressors for MAP <65
Blood cultures BEFORE antibiotics (but don't delay antibiotics >45 min for cultures)
Norepinephrine = first-line vasopressor for septic shock (more selective than dopamine; fewer arrhythmias)
Lactate >4 mmol/L = septic shock; target lactate clearance ≥10% per 2 hr
Passive leg raise test: legs elevated 45 degrees x 1 min; SBP or CO improves ≥10% = fluid responsive
Avoid large-volume NS — hyperchloremic metabolic acidosis; prefer LR

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