Assessment of vital signs and Early Warning Scores

Introduction Identification Explanation Consent

Count how many times their chests rises over 30-60 secs then work out
breaths/min. (Pretend to take pulse whilst work out respiration rate
Respiration Rate (12-20 breaths/min)
because patients may breathe slower or faster when they know you’re
taking the measurement.)

Pulse oximetry - The probe is placed on a fingertip or earlobe. The finger

O2 Saturations (≥96%) should be at rest in order to minimise motion artefact. Readings should be
taken for at least 5 minutes.

Place a sheathed thermometer probe under the tongue, into the axilla, per
Temperature (36.1-38°C depending
rectum or into the ear canal. Remove the thermometer when the device
on site)
bleeps, note the temperature and dispose of sheath.

Often taken with automated machines to remove person-to-person

Systolic BP (111-219 mmHg)
variability but manual auscultation is still required at times.

Usually the radial pulse is used to assess rate, rhythm and volume, carotid
Hear rate (51-90bpm)
pulse for pulse character and the radial/femoral pulses for pulse symmetry.

Patient at risk if only responding to pain or unresponsive.

1. Alert
Levels of consciousness - AVPU 2. Voice response
3. Pain response
4. Unresponsive