Vital Signs

The Five Vital Signs Level of responsivenessLevel of responsiveness BreathingBreathing PulsePulse TemperatureTemperature Blood pressureBlood pressure

Other Signs

Skin temperature, moisture & colorSkin temperature, moisture & color Capillary refill timeCapillary refill time State of the pupilsState of the pupils Ability to moveAbility to move Response to pain and touchResponse to pain and touch

AVPUAAlertlertVVerbal stimulierbal stimuliPPainainUUnresponsivenresponsive

A

V

P

U

Breathing

NormalNormal 12-20/min adults12-20/min adults 15-30/children 15-30/children

Labored breathingLabored breathing Ineffective breathingIneffective breathing

CyanosisCyanosis blue discoloration of skin, lips & nailsblue discoloration of skin, lips & nails

Altered mental statusAltered mental status

Breathing - Other Signs

NoiseNoise OdorOdor

oral hygieneoral hygiene alcoholalcohol indigestionindigestion diabetesdiabetes kidney failurekidney failure poisonspoisons

The Pulse

RateRate 50-90 bpm/adult50-90 bpm/adult 80-100 bpm/child 80-100 bpm/child don’t use your thumbdon’t use your thumb

RhythmRhythm StrengthStrength

Normal Pulse

Healthy personHealthy person Uncomplicated high blood pressureUncomplicated high blood pressure Early shockEarly shock

Strong, Slow Pulse

SleepSleep Simple faintingSimple fainting Early increased intracranial pressureEarly increased intracranial pressure Well-conditioned athleteWell-conditioned athlete

Weak, Slow Pulse

HypothermiaHypothermia Late increased intracranial pressureLate increased intracranial pressure

Strong, Fast Pulse

Early heat strokeEarly heat stroke FeverFever Overactive thyroid glandOveractive thyroid gland Early shockEarly shock Excitement or frightExcitement or fright Strenuous physical activityStrenuous physical activity

Weak, Fast Pulse

Overwhelming infectionOverwhelming infection Late heat strokeLate heat stroke Late shockLate shock Diabetic comaDiabetic coma Some types of heart diseaseSome types of heart disease

Irregular Pulse

Sinus arrhythmiaSinus arrhythmia Some types of heart diseaseSome types of heart disease

Pulse Assessment Locations

Carotid arteryCarotid artery Femoral arteryFemoral artery Radial pulseRadial pulse Brachial pulseBrachial pulse Dorsalis pedis pulseDorsalis pedis pulse Posterior tibial pulsePosterior tibial pulse

Temperature

Normal: 98.6 ° F (37°C)Normal: 98.6 ° F (37°C) Hypothermia: 95°F (35°C)Hypothermia: 95°F (35°C) LocationsLocations

OralOral EarEar AxillaryAxillary RectalRectal

Blood pressure

Systolic pressureSystolic pressure Diastolic pressureDiastolic pressure Pulse pressure Pulse pressure How to evaluateHow to evaluate

AuscultationAuscultation PalpationPalpation

Skin Temperature, Moisture and Color Red, moist, warm skinRed, moist, warm skin Red, dry, warm skinRed, dry, warm skin Pale, moist, cool skinPale, moist, cool skin Pale, dry, cool skinPale, dry, cool skin Blue skinBlue skin Yellow skinYellow skin

Capillary Refill Time

Reaction of the Pupils

ConstrictedConstricted DilatedDilated

Pupillary Changes

Normal pupilsNormal pupils Pinpoint pupilsPinpoint pupils Large pupilsLarge pupils Unequal pupilsUnequal pupils

Reaction to Pain & Touch

FeelingFeeling LocalizationLocalization

Ability to Move

Free movementFree movement Resisted movementResisted movement WeaknessWeakness One side vs. both sidesOne side vs. both sides ParalysisParalysis

Triad

Level of responsivenessLevel of responsiveness State of pupilsState of pupils Lateralized extremity weaknessLateralized extremity weakness