SIRS - Systemic Inflammatory Response Syndrome
Evaluator's Name_____________________________________ Date of Assessment
SIRS and Sepsis Assessment
Assess the patient and complete the appropriate dropdown response.
How is your patient doing?
Does your Healthcare Provider (HCP) need to know your assessment?
The earlier this is assessed, reported, and treated, the better outcomes the patient may have.
Temperature greater than 38 degrees Celsius (100.4 degrees Fahrenheit)
Or
less than 36 degrees Celsius (96.8 degrees Fahrenheit)
Heart Rate greater than 90 beats per minute
Respiratory Rate greater than 20 or PaCO2 less than 32 mmHg
White Blood Cell Count (WBC) greater than 12,000 mm3, less than 4,000/mm3, or greater than 10% bands
SEPSIS CRITERIA (SIRS + Source of Infection
Suspected or present source of infection
SEVERE SEPSIS CRITERIA (Organ Dysfunction, Hypotension, or Hypoperfusion)
Lactic acidosis (Lactic acid level > 2 mmol/L, SBP less than 90 mmHg or SBP drop 40 mmHg or more
SEPTIC SHOCK CRITERIA
Severe sepsis with hypotension, despite adequate fluid resuscitation
MULTIPLE ORGAN DYSFUNCTION SYNDROME CRITERIA
Evidence of ≥2 organs failing
