VSS Flashcards
(21 cards)
PSA - Adequate Perfusion
Skin: Warm, Pink, Dry
Pulse: 60 - 100 bpm
BP: more than 100 mmHg systolic
Conscious State: Alert and orientated to time and place
PSA - Borderline Perfusion
Skin: Cool, Pale, Clammy
Pulse: 50 - 100 bpm
BP: 80 - 100 mmHg systolic
Conscious State: Alert and orientated to time and place
PSA - Inadequate Perfusion
Skin: Cool, Pale, Clammy
Pulse: less than 50 bpm OR more than 100 bpm
BP: 60 - 80 mmHg systolic
Conscious State: Either alert and orientated OR altered
PSA - Extremely Poor Perfusion
Skin: Cool, Pale, Clammy
Pulse: less than 50 bpm OR more than 100 bpm
BP: less than 60 mmHg systolic
Conscious State: Altered or unconscious
PSA - No perfusion
Skin: Cool, Pale, Clammy
Pulse: N/A
BP: N/A
Conscious State: Unconscious
PSA - Adequate Newborn
Age: Less than 24 Hours
Skin: Warm, Pink, Dry
Heart Rate: 110 - 170 bpm
BP: More than 60 mmHg
Conscious State: Alert and active
PSA - Adequate Small Infant
Age: Less than 3 months
Skin: Warm, Pink, Dry
Heart Rate: 110 - 170 bpm
BP: More than 60 mmHg
Conscious State: Alert and active
PSA - Adequate Large Infant
Age: 3 - 12 months
Skin: Warm, Pink, Dry
Heart Rate: 105 - 165 bpm
BP: More than 65 mmHg
Conscious State: Alert and active
PSA - Adequate Small Child
Age: 1 - 4 years
Skin: Warm, Pink, Dry
Heart Rate: 85 - 150 bpm
BP: More than 70 mmHg
Conscious State: Alert and active
PSA - Adequate Medium Child
Age: 5 - 11 years
Skin: Warm, Pink, Dry
Heart Rate: 70 - 135 bpm
BP: More than 80 mmHg
Conscious State: Alert and active
PSA - Adequate Adolescent
Age: 12 - 15 years
Skin: Warm, Pink, Dry
Heart Rate: 60 - 120 bpm
BP: More than 90 mmHg
Conscious State: Alert and active
RSA - Normal
Appearance: Calm, quiet
Speech: Clear, steady sentences
Sounds: Usually quiet, no wheezing/crackles
Rate: 12 - 16 breaths per minute
Rhythm: Regular, even cycles
Effort: Normal/ No effort
HR: 60 - 100 bpm
Skin: Normal
Conscious State: Alert
RSA - Mild Distress
Appearance: Calm or midly anxious
Speech: Full sentences
Sounds: Able to cough.
- Asthma : mild expiratory wheeze
- LVF fine crackles at basees
Rate: 16 - 20 breaths per minute
Rhythm: Asthma : slightly prolonged expiratory phase
Effort: Slight increase in normal chest movement
HR: 60 - 100 bpm
Skin: Normal
Conscious State: Alert
RSA - Moderate Distress
Appearance: Distressed or anxious
Speech: Short phrases only
Sounds: Able to cough
- Asthma: expiratory (maybe inspiratory wheeze
- LVF: Crackles at bases to midzone
Rate: More than 20 breaths per minute
Rhythm: Asthma: Prolonged expiratory phase
Effort:Marked chest movement, potentially use of accessory muscles
HR: 100 - 120 bpm
Skin: Pale and sweaty
Conscious State: May be altered
RSA - Severe Distress
Appearance: Distressed, anxious, exhauseted, fighting to breathe, catatonic
Speech: Words only or unable to speak
Sounds: Unable to cough
- Asthma: Expiratory wheeze (maybe inspiratory wheeze), maybe no breath sounds
- LVF: Fine crackles, full field with possible wheeze
- UAO: Stridor
Rate: More than 20 breaths per minute/ less than 8 breaths per minute
Rhythm: Asthma: prolonged expiratory phase
Effort: Marked chest movements with accessory muscle use, intercostal retraction + tracheal tugging
HR: More than 120 bpm
Skin: Pale and sweaty, cyanosis
Conscious State: Altered or unconscious
RSA - Adequate Newborn
Age: Less than 24 hours
Rate of breathing: 25 - 60 breaths per minute
RSA - Adequate Small Infant
Age: Less than 3 months
Rate of breathing: 25 - 60 breaths per minute
RSA - Adequate Large Infant
Age: 3 - 12 months
Rate of breathing: 25 - 55 breaths per minute
RSA - Adequate Small Child
Age: 1 - 4 years
Rate of breathing: 20 - 40 breaths per minute
RSA - Adequate Medium Child
Age: 5 - 11 years
Rate of breathing: 16 - 34 breaths per minute
RSA - Adequate Adolescent
Age: 12 - 15 years
Rate of breathing: 14 - 26 breaths per minute
