Pulse | Blood Pressure | Respirations | Vital Signs By Age | Lung sounds | Pulse oximetry
Glasgow Coma Scale | Apgar scale | Pain Scale


Pulse
Descriptors: regular, irregular, strong or weak
Adult60 to 100 beats per minute
Children – age 1 to 8 years80 to 100
Infants – age 1 to 12 months100 to 120
Neonates – age 1 to 28 days120 to 160
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Blood pressure
SystolicDiastolic
Adult90 to 140 mmHg60 to 90 mmHg
Children – age 1 to 8 years80 to 110 mmHg
Infants – age 1 to 12 months70 to 95 mmHg
Neonates – age 1 to 28 days>60 mmHg
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Respirations
Descriptors: normal, shallow,
labored, noisy, Kussmaul
Adult (normal)12 to 20 breaths per minute
Children – age 1 to 8 years15 to 30
Infants – age 1 to 12 months25 to 50
Neonates – age 1 to 28 days40 to 60
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Vital signs by age
Adult vital signs
Pulse60 to 100 beats per minute
Blood pressure90 to 140 mmHg (systolic)

60 to 90 mmHg (diastolic)

Respirations12 to 20 breaths per minute
Child vital signs
(age 1 to 8 years)
Pulse80 to 100 beats per minute
Blood pressure80 to 110 mmHg systolic
Respirations15 to 30 breaths per minute
Infant vital signs
Pulse100 to 140 beats per minute
Blood pressure70 to 95 mmHg systolic
Respirations25 to 50 breaths per minute
Neonatal vital signs
(full-term, <28 days)
Pulse120 to 160 beats per minute
Blood pressure>60 mmHg systolic
Respirations40 to 60 breaths per minute
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Lung sounds
Crackles or ralescrackling or rattling sounds
Wheezinghigh-pitched whistling expirations
Stridorharsh, high-pitched inspirations
Rhonchicoarse, gravelly sounds
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Pulse oximetry
RangeValueTreatment
Normal95 to 100%None or placebic
Mild hypoxia91 to 94%Give oxygen
Moderate hypoxia86 to 90%Give 100% oxygen
Severe hypoxia< 85%Give 100% oxygen w/ positive pressure
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Glasgow Coma Scale
ADULTINFANT
Eye openingEEye opening
Spontaneous4Spontaneous
To speech3To speech
To pain2To pain
No response1No response
Best motor responseMBest motor response
Obeys verbal command6Normal movements
Localizes pain5Localizes pain
Flexion – withdraws from pain4Withdraws from pain
Flexion – abnormal3Flexion – abnormal
Extension2Extension
No response1No response
Best verbal responseVBest verbal response
Oriented and converses5Coos, babbles
Disoriented and converses4Cries but consolable
Inappropriate words3Persistently irritable
Incomprehensible sounds2Grunts to pain/restless
No response1No response
E + M + V = 3 to 15
  • 90% less than or equal to 8 are in coma
  • Greater than or equal to 9 not in coma
  • 8 is the critical score
  • Less than or equal to 8 at 6 hours – 50% die
  • 9-11 = moderate severity
  • Greater than or equal to 12 = minor injury

Coma is defined as not opening eyes, not obeying commands, and not uttering
understandable words.

Additional references:
Traumatic Brain Injury Resource Guide and House of DeFrance.
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Apgar Scale
(evaluate @ 1 and 5 minutes postpartum)
Sign210
AActivity (muscle tone)ActiveArms and legs flexedAbsent
PPulse>100 bpm<100 bpmAbsent
GGrimace (reflex irritability)Sneezes, coughs, pulls awayGrimacesNo response
AAppearance (skin color)Normal over entire bodyNormal except extremitiesCyanotic or pale all over
RRespirationsGood, cryingSlow, irregularAbsent
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Pain scale
The 0-10 pain scale is becoming known
as the “fifth vital sign” in hospital, pre-hospital and outpatient care.
Patients are asked to rate their pain from 0 (no pain) to 10 (the most intense pain
imaginable), and a quantitative measure is taken.
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