Establish a baseline and get insight into tricky diagnoses.
Responsiveness Judge alertness: Ask questions or cause minor pain (like pinching).
|Knows name, day, place, and what happened||Can answer two or fewer of these key questions|
|Heart Rate Press two fingers into the wrist artery (below the thumb). Count pulse for 15 seconds and multiply by 4.|
|50-100 beats per minute, regular and strong||Less than 40 bpm or more than 130 bpm|
|Respiratory Rate Look, listen, and feel the abdomen for breathing. Count the rise and fall of the chest as one breath.|
|12-20 breaths per minute, regular and unlabored||Less than 8 or more than 20 breaths per minute|
|Skin color, Temperature, moisture Examine non-pigmented skin (nailbeds, palms, eyes), and feel near core.|
|Pink, warm, and dry||Hot and dry, or frozen and chalky|
|Blood pressure Look for responsiveness, skin condition, and pulse indicators.|
Under 70 mmHg
|Pupils Briefly shine light into each eye and watch for response. In sunlight: Shade the eyes, then remove the shade.|
|Equal, round, light-reactive||Not light-
|Temperature Use a thermometer orally, rectally, or in the armpit; estimate by feeling forehead.|
|98.6°F||Less than 95°F;
more than 101°F