BASIC NURSING

KNOWLEDGE AND SKILLS

VITAL SIGNS
TEMPERATURE
• 36.5 – 37.5 °C axillary area

RESPIRATION
Adult (normal) 12 to 20 breaths per minute

Adolescent 12 to 20

School-age- 6 to 12 years 15 to 25

Toddler- age 2 to 5 years 20 to 35

Infants - age 1 to 12 months 25 to 40

Neonates - age 1 to 28 days 40 to 60

PULSE

Adult 60 to 100 beats per minute

Adolescent 60 to 100

School-age 70 to 100

Toddler 80 to 110

Infants 100 to 120

Neonates - age 1 to 28
120 to 160
days
BLOOD PRESSURE

Systolic Diastolic

Adult 90 to 130 mmHg 60 to 90 mmHg

Adolescent 90 to 130 mmHg 60 to 80 mmHg

School-age 90 to 110 mmHg 50 to 70 mmHg

Toddler 70 to 100 mmHg 45 to 65 mmHg

Infants 60 to 90 mmHg 30 to 55 mmHg

Neonates - age 1 to >60 mmHg

28 days
Lung sounds
Crackles or rales crackling or rattling sounds
Wheezing high-pitched whistling expirations
Stridor harsh, high-pitched inspirations
Rhonchi coarse, gravelly sounds

Pulse oximetry
Range Value Treatment
Normal 95 to 100% None or placebic
Mild hypoxia 91 to 94% Give oxygen
Moderate hypoxia 86 to 90% Give 100% oxygen
Severe hypoxia <85% Give 100% oxygen
w/ positive pressure
 NEURO VITAL SIGNS
ADULT INFANT
Eye opening E Eye opening
Spontaneous 4 Spontaneous
To speech 3 To speech
To pain 2 To pain
No response 1 No response
Best motor response M Best motor response
Obeys verbal command 6 Normal movements
Localizes pain 5 Localizes pain
Flexion - withdraws from
4 Withdraws from pain
pain
Flexion - abnormal 3 Flexion - abnormal
Extension 2 Extension
Best verbal Best verbal
V
response response
Oriented and
5 Coos, babbles
converses
Disoriented and Cries but
4
converses consolable
Inappropriate Persistently
3
words irritable
Incomprehensible Grunts to
2
sounds pain/restless
No response 1 No 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.
For children under 5, the verbal response criteria are adjusted
as follow:

2 to 5 YRS 0 TO 23 Mos.
SCORE

Appropriate words or
5 Smiles or coos appropriately
phrases
4 Inappropriate words Cries and consolable
Persistent cries and/or Persistent inappropriate crying &/or
3
screams screaming
2 Grunts Grunts or is agitated or restless
1 No response No response
"Keep in mind that the true
measure of an individual is how
he treats a person who can do
him absolutely no good."
—Ann Landers