Vital Signs

The Five Vital Signs n Level of responsiveness n Breathing n Pulse n Temperature n Blood pressure

Other Signs n Skin temperature, moisture & color n Capillary refill time n State of the pupils n Ability to move n Response to pain and touch

AVPU g A lert g V erbal stimuli g P ain g U nresponsive AVPUAVPU

Breathing n Normal u 12-20/min adults u 15-30/children n Labored breathing n Ineffective breathing u Cyanosis F blue discoloration of skin, lips & nails u Altered mental status

Breathing - Other Signs n Noise n Odor u oral hygiene u alcohol u indigestion u diabetes u kidney failure u poisons

The Pulse n Rate u bpm/adult u bpm/child u don’t use your thumb n Rhythm n Strength

Normal Pulse n Healthy person n Uncomplicated high blood pressure n Early shock

Strong, Slow Pulse n Sleep n Simple fainting n Early increased intracranial pressure n Well-conditioned athlete

Weak, Slow Pulse n Hypothermia n Late increased intracranial pressure

Strong, Fast Pulse n Early heat stroke n Fever n Overactive thyroid gland n Early shock n Excitement or fright n Strenuous physical activity

Weak, Fast Pulse n Overwhelming infection n Late heat stroke n Late shock n Diabetic coma n Some types of heart disease

Irregular Pulse n Sinus arrhythmia n Some types of heart disease

Pulse Assessment Locations n Carotid artery n Femoral artery n Radial pulse n Brachial pulse n Dorsalis pedis pulse n Posterior tibial pulse

Temperature n Normal: 98.6 ° F (37°C) n Hypothermia: 95°F (35°C) n Locations u Oral u Ear u Axillary u Rectal

Blood pressure n Systolic pressure n Diastolic pressure n Pulse pressure n How to evaluate u Auscultation u Palpation

Skin Temperature, Moisture and Color n Red, moist, warm skin n Red, dry, warm skin n Pale, moist, cool skin n Pale, dry, cool skin n Blue skin n Yellow skin

Capillary Refill Time

Reaction of the Pupils n Constricted n Dilated

Pupillary Changes n Normal pupils n Pinpoint pupils n Large pupils n Unequal pupils

Reaction to Pain & Touch n Feeling n Localization

Ability to Move n Free movement n Resisted movement n Weakness n One side vs. both sides n Paralysis

Triad n Level of responsiveness n State of pupils n Lateralized extremity weakness