Vital Signs - Adult
- Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
- Rectal
- Tympanic
- Oral
- Axillary
- Temporal
- Respiration (12-20)
- Oxygen Saturation (94%-100%)
- Pulse (60-100)
- Blood Pressure (<120/80)
- Pain
Neurovascular Assessment 6 P's
- Pain
- Paresthesia
- Pulse
- Pallor
- Pressure
- Paralysis
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
- Confused
- Delirious
- Somnolent
- Obtunded
- Stuporous
- Comatose
Pain Assessment
- Acute Pain
- Chronic Pain
- Onset
- Provoking or Palliative
- Quality
- Radiation
- Severity
- Timing
- Subjective Findings
- Objective Findings
- Reassessment of Pain
Child and Elder Physical Abuse Assessment
- Inconsistent Injuries
- Delay in Treatment
- Various Stages of Healing
- Symmetrical Burns
- Sexually Transmitted Infection
- Bloody/Torn Undergarments
- Shaken Baby Syndrome
- Poor Hygiene
- Overmedication
Fever
- Flushed skin, warm to touch
- Chills
- Sweating
- Change in LOC
- Provide adequate fluids
- Monitor Electrolytes and Fluid
- Monitor vital signs, esp temperature
- Remove excess clothing and blankets
- Sponge bath with tepid water