Face to face assessment

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Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.3 Initial assessment and examination

1.3.1

Assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in people aged 12 or over with suspected sepsis. [2016]

1.3.2

Assess temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation and capillary refill time in children under 12 with suspected sepsis. [2016]

1.3.3

Measure blood pressure of children under 5 if heart rate or capillary refill time is abnormal and equipment is available, including a correctly-sized blood pressure cuff. In community settings, only do this if taking a measurement does not cause a delay in assessment or treatment. [2016]

1.3.4

Measure blood pressure of children aged 5 to 11 who might have sepsis if equipment is available, including a correctly-sized cuff. In community settings, only do this if taking a measurement does not cause a delay in assessment or treatment. [2016]

1.3.5

In community settings, measure oxygen saturation if equipment is available and taking a measurement does not cause a delay in assessment or treatment. [2016]

1.3.6

Examine people with suspected sepsis for:

  • mottled or ashen appearance

  • cyanosis of the skin, lips or tongue

  • non-blanching petechial or purpuric rash

  • any breach of skin integrity (for example, cuts, burns or skin infections)

  • other rash indicating potential infection.

    For signs and symptoms of meningococcal disease, see the NICE guideline on bacterial meningitis and meningococcal disease. [2016, amended 2024]

1.3.7

Ask the person or their family or carers how often the person urinated in the past 18 hours. [2016]

1.3.8

Ask the person with suspected sepsis and their family or carers about any recent fever or rigors. [2016]

1.3.9

Ask the person if they have recently presented (for example to their GP or to hospital) with symptoms or signs that could indicate sepsis. [2024]

For a short explanation of why the committee made the 2024 recommendation and how it might affect practice, see the rationale and impact section on initial assessment and examination.

Full details of the evidence and the committee's discussion are in evidence review C: early management of suspected sepsis (except antibiotic therapy) in the NEWS2 population, in acute hospital settings.

1.3.10

As part of the initial assessment, carry out a thorough clinical examination to look for sources of infection, including sources that might need drainage or other interventions. Follow the recommendations on finding and controlling the source of infection. [2016, amended 2024]

1.4 Interpreting findings

Temperature in suspected sepsis

1.4.1

Do not rely on fever or hypothermia alone to rule sepsis either in or out. [2016]

1.4.2

Take into account that some groups of people with sepsis may not develop a raised temperature. These include:

  • people who are older or very frail

  • people having treatment for cancer

  • people severely ill with sepsis

  • young infants or children

  • people with a spinal cord injury [2016, amended 2024]

1.4.3

Take into account that a rise in temperature can be a physiological response, for example after surgery or trauma. [2016]

Heart rate in suspected sepsis

1.4.4

Interpret the heart rate of a person with suspected sepsis in context, taking into account that:

  • baseline heart rate may be lower in young people and adults who are fit

  • baseline heart rate in pregnancy is 10 to 15¬†beats per minute more than normal

  • older people with an infection may not develop an increased heart rate

  • older people may develop a new arrhythmia in response to infection rather than an increased heart rate

  • heart rate response may be affected by medicines such as beta-blockers. [2016]

Blood pressure in suspected sepsis

1.4.5

Interpret blood pressure in the context of a person's previous blood pressure, if known. Be aware that the presence of normal blood pressure does not exclude sepsis in children and young people. [2016]

Confusion, mental state and cognitive state in suspected sepsis

1.4.6

Interpret a person's mental state in the context of their normal function and treat changes as being significant. [2016]

1.4.7

Be aware that changes in cognitive function may be subtle and assessment should include history from the patient and their family or carers. [2016]

1.4.8

Take into account that changes in cognitive function may present as changes in behaviour or irritability in both children and adults with a learning disability or dementia. [2016, amended 2024]

1.4.9

Take into account that changes in cognitive function in older people may present as acute changes in functional abilities. [2016]

Oxygen saturation in suspected sepsis

1.4.10

Take into account that if peripheral oxygen saturation is difficult to measure in a person with suspected sepsis, this may indicate poor peripheral circulation because of shock. [2016]

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

  • National Institute for Health and Care Excellence (NICE)