Vital Signs

Question 1

GCS

Answer 1

Eyes/4
Open Spontaneously
Open to speech
Open to pain
Do not open

Voice/5
Oriented to time, place and person
Confused
Inappropriate words
Incomprehensible sounds
No response

Motor/6
Obeys commands
Moves to localised pain
Flexion withdrawal with pain
Abnormal flexion
Abnormal extension
No response

Question 2

Blood Pressure

Answer 2

Normotensive =  120/80
Hypertensive = systolic over 140 and diastolic over 90
Hypotensive = systolic less than 90 and diastolic less than 60

Question 3

Heart Rate

Answer 3

Normal = 60 - 100 beats per minute
Tachycardia = greater than 100bpm
Bradycardia = fewer than 60bmp

Ask if this is normal for them

Question 4

Respiration Rate

Answer 4

Normal - 12-16 breaths/min
Greater than 16 is concerning
Fewer than 12 is concerning

Consider if anxious, if medical event is occurring.

Question 5

Sp02

Answer 5

92% or above is deemed adequate

Lower ask if this is normal for them

Question 6

BSL - blood sugar level

Answer 6

Normal = 4-6mmol
Hyperglycemia = greater than 6/7
Hypoglycemia = less than 4mmol

Question 7

Temperature

Answer 7

Normal = 36.1 - 37.2
Febrile/pyrexia = greater than 37.2
Hypothermia = abnormally low temperature