2. What are Vital Signs?
Outward signs of what is going on inside the body
Importance - gives responder an idea of state of
the patient, how best to manage and if to
transport to hospital
3. What are Vital Signs? (cont’d)
Level of Consciousness
Pupils
Breathing (Respirations)
Pulse
Skin
Capillary Refill
Blood Pressure
Pulse Oximetry
Temperature
4. Level of Consciousness
The level of consciousness (LOC) is considered a vital sign.
Tells a lot about a patient’s neurologic and physiologic
status
Categories:
Conscious with an unaltered LOC
Conscious with an altered LOC
Unconscious
5. Level of Consciousness (cont’d)
Conscious with an altered LOC may be due to inadequate
perfusion.
Perfusion is the circulation of blood within an organ or
tissue.
Could also be caused by medications, drugs, alcohol, or
poisoning
6. AVPU
To assess for responsiveness, use the mnemonic AVPU:
Awake and alert
Responsive to Verbal stimuli
Responsive to Pain
Unresponsive
7. AVPU (cont’d)
Test responsiveness to painful stimuli
Pinch earlobe Press down on
bone above eye
Pinch neck
muscles
8. Level of Consciousness (cont’d)
Orientation tests mental status.
Evaluates a person’s ability to remember:
Person
Place
Time
Event
Evaluates long-term memory, intermediate-term memory,
and short-term memory
9. Glasgow Coma Scale
Used to record the conscious state of a person
Initially used to assess level of consciousness after head
injury
Now it is applicable to all acute medical and trauma
patients
Scored out of 15
10. Glasgow Coma Scale (cont’d)
Eye Response (E)
1- No eye opening
2- Eye opening in response to pain
3- Eye opening to speech
4- Eyes opening spontaneously
12. Glasgow Coma Scale (cont’d)
Motor Response (M)
1- No motor response
2- Extension to pain
3- Abnormal flexion to pain
4- Flexion/Withdrawal to pain
5- Localizes to pain
6- Obeys commands
13. Glasgow Coma Scale (cont’d)
Interpretation
Severe = GCS 8+
Moderate = GCS 9-12
Minor = GCS 13+
GCS <8 = Requires intubation
15. Pupils
Diameter and reactivity to light reflect the status of the
brain’s:
Perfusion
Oxygenation
Condition
16. Pupils (cont’d)
The pupil is a circular opening in the center of the
pigmented iris of the eye.
The pupils are normally round and of approximately
equal size.
In the absence of any light, the pupils will become fully
relaxed and dilated.
18. Pupils (cont’d)
PEARRL is a useful assessment guide:
Pupils
Equal
And
Round
Regular in size
React to Light
19. Breathing/Respiration
Make sure the patient’s breathing is present and
adequate.
Assess breathing by:
Watching the chest rise and fall
Feeling for air through the mouth and nose
Listening to breath sounds with a stethoscope over
each lung
21. Breathing/Respiration (cont’d)
Obtain the following information:
Respiratory rate
Rhythm—regular or irregular
Quality/character of breathing
Depth of breathing
22. Breathing/Respiration (cont’d)
Ask yourself these questions:
Does the patient appear to be choking?
Is the respiratory rate too fast or too slow?
Are the patient’s respirations shallow or deep?
Is the patient cyanotic (blue)?
Do I hear abnormal sounds when listening to the lungs?
Is the patient moving air into and out of the lungs on
both sides?
23. Breathing/Respiration (cont’d)
Respiratory rate
A normal rate in adults ranges from
12 to 20 breaths/min.
Children breathe at even faster rates.
Count the number of breaths in a 30-second period and
multiply by two.
While counting respirations, also note the rhythm.
26. Breathing/Respiration (cont’d)
Quality of breathing
Listen to breath sounds on each side of the chest.
Normal breathing is silent.
You can always hear a patient’s breath sounds better
from the patient’s back.
28. Breathing/Respiration (cont’d)
What are you listening for?
Normal breath sounds
Wheezing breath sounds
Rales
Rhonchi
Stridor - a high-pitched, crowing upper airway sound
29. Breathing/Respiration (cont’d)
Depth of breathing
Amount of air the patient exchanges depends on the
rate and tidal volume
Nasal flaring and seesaw breathing in pediatric patients
indicate inadequate breathing.
Normal breathing is an effortless process that does not
affect speech, posture, or positioning.
Tripod position?
30. Respiration Observations Possible Problem
Rapid & Shallow Shock, heart problems, heat emergency,
diabetic emergency
Deep, gasping and labored Airway obstruction, heart problems, lung
disease, chest injury, diabetic emergency
Too slow Head injury, stroke, chest injury, drug
overdose
Snoring Skull fracture, stroke, drug or alcohol abuse,
partial airway obstruction
Gurgling (liquid in the airway) Airway obstruction, lung disease, heat
damage to lungs, heart problems, depressed
conscious level
Wheezing Asthma, emphysema, airway obstruction,
heart failure
Coughing blood Chest wound or infection, fractured rib,
punctured lung, internal injuries
32. Circulation (cont’d)
Assess pulse
The pulse is the pressure wave that occurs as each
heartbeat causes a surge in the blood circulating
through the arteries.
Palpate (feel) the pulse.
If you cannot palpate a pulse in an unresponsive
patient, begin CPR.
33. Common Pulse Points
Central Pulses
Carotid
Femoral
Peripheral Pulses
Radial
Brachial (children under 1)
Posterior Tibial, Dorsalis Pedis
34. Circulation (cont’d)
Pulse rate
Normal resting pulse for an adult is between 60 and
100 beats/min.
The younger the patient, the faster the pulse.
36. Circulation (cont’d)
Pulse quality
Describe a stronger than normal pulse as “bounding.”
A pulse that is weak and difficult to feel is described as
“weak” or “thready.”
37. Circulation (cont’d)
Pulse rhythm
Determine whether it is regular or irregular.
When the interval between each ventricular
contraction is short, the pulse is rapid.
When the interval is longer, the pulse is slower.
38. OBSERVATION (PULSES) POSSIBLE PROBLEM
Rapid and full Early stage hemorrhage,
fear/anxiety, pain, heat
emergency, fever, high BP
Rapid and thready Shock, heat emergency, diabetic
emergency, heart problem,
falling BP
Slow and full Stroke, fractured skull, brain
injury, drug OD
No pulse Carotid = cardiac arrest
Distal to an extremity injury
(fracture, dislocation)- major
vessel damage to the area
Shock- with very low pressure
39. Circulation (cont’d)
The skin
A normally functioning circulatory system perfuses the
skin with oxygenated blood.
Evaluate the patient’s skin color, temperature,
moisture, and capillary refill.
40. Circulation (cont’d)
Skin color
Determined by the blood circulating through vessels
and the amount and type of pigment present in the
skin
Poor circulation will cause the skin to appear pale,
white, ashen, or gray.
When blood is not properly saturated with oxygen, it
appears bluish.
Changes in skin color may result from chronic illness.
42. Circulation (cont’d)
Skin temperature
Normal skin will be warm to the touch (98.6°F).
Abnormal skin temperatures are hot, cool, cold, and
clammy.
43. Circulation (cont’d)
Skin moisture
Dry skin is normal.
Skin that is wet, moist, or excessively dry and hot
suggests a problem.
44. Circulation (cont’d)
Capillary refill
Evaluated to assess the ability of the circulatory system
to restore blood to the capillary system
Press on the patient’s fingernail.
Remove the pressure.
The nail bed should restore to its normal pink color.
Should be restored to normal within 2 seconds
CRT is a common measure of dehydration and peripheral
perfusion
47. Blood Pressure
The measurement of the highest and lowest forces
exerted on the inner walls of arteries
Systolic Pressure- peak pressure in the arteries, when the
ventricles are contracting; Pressure when heart is
pumping
Diastolic Pressure- minimum pressure in the arteries
when the ventricles are filled with blood; Pressure when
heart is at rest
51. Blood Pressure (cont’d)
BP by Auscultation
Size using guides on cuff
Position on upper arm hoses pointing down
Inflate 30mmHg past pulse
Position stethoscope over brachial artery
Deflate
Note first sound and last sound
Record as systolic/diastolic (140/80)
54. Note on Vitals
First set of vitals is the baseline, you are interested in
changes
On not sick patients, repeat every 15 minutes
On sick patients, repeat every 5 minutes
Treat patient, not the vital signs or the equipment
55. Pain Scale
Another device that can be very helpful in the assessment
of pain is the mnemonic OPQRST:
O-Onset. When did the problem begin and what caused it?
P-Provocation or palliation. Does anything make it feel
better or worse? How are you most comfortable?
Q-Quality. What is the pain like? Is it sharp, dull, crushing,
tearing? Ask the patient to describe the pain.
56. Pain Scale (cont’d)
R-Region/radiation. Where does it hurt? Does the pain move
anywhere?
S-Severity. On a scale of 1 to 10, how would you rate your
pain?
T-Timing. Has the pain been constant or does it come and
go? How long have you had the pain (often answered under
“O” onset)? When did the pain start?
58. Review
1. Findings such as inadequate breathing or an altered level
of consciousness should be identified in the:
A. primary assessment.
B. full-body scan.
C. secondary assessment.
D. reassessment.
59. Review (cont’d)
Answer: A
Rationale: The purpose of the primary assessment is to
identify and manage any life threats to the patient, such as
inadequate breathing, an altered level of consciousness, or
severe hemorrhage.
60. Review (cont’d)
2. A semiconscious patient pushes your
hand away when you pinch his earlobe. You should
describe his level of consciousness as:
A. alert.
B. unresponsive.
C. responsive to painful stimuli.
D. responsive to verbal stimuli.
61. Review (cont’d)
Answer: C
Rationale: Semiconscious patients are not alert, nor are
they unresponsive. The fact that the patient pushes your
hand away when you pinch his earlobe indicates that he is
responsive to painful stimuli. If he opens his eyes or
responds when you speak to him, he would be described as
being responsive to verbal stimuli.
62. Review (cont’d)
3. Assessment of an unconscious patient’s breathing begins
by:
A. inserting an oral airway.
B. manually positioning the head.
C. assessing respiratory rate and depth.
D. clearing the mouth with suction as needed.
63. Review (cont’d)
Answer: B
Rationale: You cannot assess or treat an unconscious
patient’s breathing until the airway is patent—that is, open
and free of obstructions. Manually open the patient’s airway
(eg, head tilt–chin lift, jaw-thrust), use suction as needed to
clear the airway of blood or other liquids, insert an airway
adjunct to assist in maintaining airway patency, and then
assess the patient’s respiratory effort.
64. Review (cont’d)
4. Your 12-year-old patient can speak only two or three
words without pausing to take a breath. He has a serious
breathing problem known as:
A. nasal flaring.
B. two- to three-word dyspnea.
C. labored breathing.
D. shallow respirations.
65. Review (cont’d)
Answer: B
Rationale: Two- to three-word dyspnea is a severe breathing
problem in which a patient can speak only two to three
words at a time without pausing to take a breath.
66. Review (cont’d)
5. How should you determine the pulse in an unresponsive
8-year-old patient?
A. Palpate the radial pulse at the wrist.
B. Palpate the brachial pulse inside the upper arm.
C. Palpate the radial pulse with your thumb.
D. Palpate the carotid pulse in the neck.
67. Review (cont’d)
Answer: D
Rationale: In unresponsive patients older than 1 year, you
should palpate the carotid pulse in the neck. If you cannot
palpate a pulse in an unresponsive patient, begin CPR.
68. Review (cont’d)
6. When assessing your patient’s pain, he says it started in
his chest but has spread to his legs. This is an example
of what part of the OPQRST mnemonic?
A. Onset
B. Quality
C. Region/radiation
D. Severity
69. Review (cont’d)
Answer: C
Rationale: The region/radiation section of the OPQRST
mnemonic assesses a patient’s pain—where it hurts and
where the pain has spread. Because the patient informed
you that his pain spread from his chest to his legs, this would
be an example of radiation.
70. Review (cont’d)
7. Which of the following conditions would be LEAST likely to
cause an altered level of consciousness?
A. drug overdose
B. inadequate perfusion
C. acute anxiety
D. poisoning
72. Review (cont’d)
8. Which of the following patients does NOT have an altered
mental status?
A. a patient with an acute allergic reaction and dizziness
B. a diabetic who opens his eyes when you ask questions
C. a patient with a head injury who is slow to answer
questions
D. a patient who overdosed and moans when he is
touched
74. Review (cont’d)
9. A patient who does not respond to your questions but
moves or cries out when his or her trapezius muscle is
pinched, is said to be:
A. conscious and alert.
B. completely unresponsive.
C. responsive to verbal stimuli.
D. responsive to painful stimuli.
76. Review (cont’d)
10.An elderly patient has fallen and hit her head. You assess
her level of consciousness as unresponsive using the AVPU
scale. Your initial care should focus on:
A. obtaining baseline vital signs.
B. gathering medical history data.
C. providing immediate transport.
D. airway, breathing, and circulation.
78. Review (cont’d)
11.A patient’s short-term memory is MOST likely intact if he
or she correctly answers questions regarding:
A. time and place.
B. date and event.
C. event and person.
D. person and place.
80. Review (cont’d)
12.A 29-year-old male with a head injury opens his eyes when
you speak to him, is confused as to the time and date, and
is able to move all of his extremities on command. His
Glasgow Coma Scale (GCS) score is:
A. 10.
B. 12.
C. 13.
D. 14.
82. Review (cont’d)
13.An injured patient is assigned a total score of 9 on the
GCS. He is assigned a score of 2 for eye opening, a score
of 3 for verbal response, and a score of 4 for motor
response. Which of the following clinical findings is
consistent with his GCS score?
A. opens eyes in response to voice, makes
incomprehensible sounds, localizes pain
B. opens eyes in response to pain, uses inappropriate
words, withdraws from pain
C. opens eyes spontaneously, is confused when spoken
to, exhibits abnormal flexion
D. eyes remain closed, makes incomprehensible sounds,
exhibits abnormal extension
84. Review (cont’d)
14.When you inspect a patient’s pupils with a penlight, the
pupils should normally react to the light by:
A. constricting.
B. enlarging.
C. dilating.
D. fluttering.
86. Review (cont’d)
15.When you shine a light into one pupil, the normal reaction
of the other pupil should be to:
A. dilate.
B. not react.
C. become larger.
D. become smaller.
