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Vital Signs & Lab Values
Vital Signs
GCS: ≤ 12
Temperature: ≤ 95
o
or ≥ 104
o
Respirations: intercostal, supraclavicular, nasal flaring, tachypnea, Cheyne-Stokes
Heart rate: ≤ 40 or ≥ 150
SBP: ≤ 70 or ≥ 230
DBP: ≤ 40 or ≥ 130
O
2
saturation (pulse ox) ≤ 90%
Respiration < 5 or > 25
Electrolytes
Sodium (Na): < 120 or > 150
Potassium (K): < 2.5 or > 6.5
Calcium (Ca): < 6 or > 13
Magnesium (Mg): < 1.5 or > 5
Bicarbonate (CO
2
): < 10 or > 40
Platelets: < 20,000
