MINI NURSES | PATIENT SAFETY
An infection becomes more dangerous when a change in the patient is noticed but not acted on.
This guide focuses on recognising concern, asking for urgent review and keeping reassessment going.
A patient admitted with an infection becomes unusually quiet. Another starts breathing faster. A relative says, “This is not how she was this morning.” These observations deserve an assessment, not a quick reassurance. Nursing vigilance means connecting what you see, what you measure and what the patient or family tells you, then making sure the right person hears your concern.
What makes sepsis an emergency?
Sepsis is life-threatening organ dysfunction arising from the body’s response to infection. It can progress to shock and organ failure. WHO identifies confusion, breathing difficulty, a rapid pulse, low blood pressure, low urine output, abnormal temperature and clammy skin among its warning signs. These findings can also have other causes: they call for urgent assessment rather than a bedside assumption that sepsis is confirmed. [1]
Seven changes worth reporting clearly
| Change | What to communicate |
|---|---|
| New confusion or reduced alertness | What changed, when it started and the patient’s usual mental state. |
| Breathing difficulty or a rising respiratory rate | The measured rate, work of breathing, oxygen saturation and oxygen support. |
| A fast pulse or falling blood pressure | Current observations alongside earlier readings. |
| Reduced urine output | The amount and time interval, or that reliable measurement is unavailable. |
| High or low temperature with illness | The actual temperature, timing and associated symptoms. |
| Clammy skin or marked discomfort | Your assessment and the patient’s description. |
| Deterioration despite ongoing care | What has worsened, what has already been done and the response. |
Use exact observations wherever possible. “Respiratory rate increased from 18 to 30” gives a reviewer more information than “breathing is somehow fast.” If equipment is unavailable, state the limitation and describe what you can assess; do not invent a reading.
Assess, call for help and reassess
Use an ABCDE assessment: airway, breathing, circulation, disability and exposure. Identify immediate threats, seek appropriate help early and act within your competence and local emergency protocol. Reassess after interventions and communicate whether the patient improves. If the patient becomes unresponsive and is not breathing normally, activate the emergency response and begin resuscitation according to your training and local protocol. [2]
Escalation is a conversation with an outcome. Make it clear that you are requesting urgent bedside assessment. If the first person contacted cannot respond, follow your facility’s escalation pathway and contact the appropriate senior clinician or emergency team. Record the times, the observations, who was contacted, the advice received and the subsequent response. Documentation supports care; it should accompany urgent action.
A score supports judgement
Where NEWS2 is used, calculate it accurately and follow the response pathway. NICE recommends it for suspected sepsis in specified acute-care settings for people aged 16 or over who are not pregnant or recently pregnant. Clinical concern, deterioration or failure to improve may justify a higher level of concern than the score alone suggests. Children and pregnant or recently pregnant patients need the appropriate separate assessment pathways. [3] [4]
NICE’s adult guidance recommends intravenous broad-spectrum antibiotics within one hour of the initial NEWS2 assessment for people at high risk of severe illness or death from sepsis. This is not a universal antibiotic instruction for every fever: treatment depends on risk assessment, authorised prescribing and the local pathway. Nurses help by escalating promptly, preparing prescribed care and reporting delays. [5]
A ward scenario: make the concern unmistakable
Fictional learning example, not a patient record: A 54-year-old admitted with a chest infection becomes newly confused. Respiratory rate rises from 20 to 30 per minute, pulse is 118 and blood pressure is 94/60 mmHg. These findings warrant urgent clinical review; do not wait for the next routine observation round.
Situation: I am calling about a deteriorating patient in bed 6. I need an urgent bedside review.
Background: The patient is being treated for a chest infection and was alert earlier.
Assessment: There is new confusion, respiratory rate 30, pulse 118 and blood pressure 94/60. I am concerned about possible sepsis.
Recommendation: Please assess the patient now. I am continuing assessment and monitoring and will activate the emergency pathway if needed.
The strength of this handover is its precision. It identifies the patient, describes the change and asks for an action. Add oxygen saturation, oxygen delivery, urine output, relevant treatment and allergies when available. Do not delay an urgent call to complete every detail.
The message to carry into your next shift
Listen when a patient says something feels wrong. Take a relative’s account seriously. Check observations, compare them with the earlier picture and explain your concern clearly. A useful question before leaving the bedside is: “If this patient worsens in the next few minutes, does the team know what I have just noticed?”
For students, asking for help is part of safe practice. For experienced nurses, explaining why you are concerned helps the whole team respond. Recognition matters most when it leads to timely assessment and continued follow-up.
Sources and further reading
- World Health Organization: Sepsis fact sheet.
- Resuscitation Council UK: The ABCDE Approach.
- NICE NG253: Could this be sepsis?
- NICE NG253: Evaluating risk.
- NICE NG253: Managing suspected sepsis.
Sources checked 1 November 2026. Educational guidance for nurses and students; apply your facility’s current protocols and scope of practice. NICE guidance is UK guidance and is not presented as a Nigerian national protocol.