Assessments (Adult)

Perfusion Status Assessment
	Adequate	Borderline	Inadequate	Extremely Poor
Skin	Warm, pink, dry	Cool, pale, clammy	Cool, pale, clammy	Cool, pale, clammy
Pulse	60-100/min	50-100/min	<50/min or >100/min	<50/min or >110/min
BP	>100 mmHg	80-100 mmHg	60-80 mmHg	<60> mmHg
Conscious State	Alert and oriented in time and place	Alert and oriented in time and place	Either alert and oriented in time and place or altered	Altered or unconscious

Respiratory Status Assessment
	Normal	Mild Distress	Moderate Distress	Severe Distress
General	Calm, quiet	Calm or mildly anxious	Distressed or anxious	Distressed, anxious, fighting to breath, exhausted, catatonic
Speech	Clear and steady sentences	Full sentences	Short phrases only	Words only or unable to speak
Breath Sounds and Chest Auscultation	Usually quiet	Able to cough	Able to cough	Unable to cough
	No wheeze	Asthma: Mild expiratory wheeze	Asthma: Expiratory wheeze +/- inspiratory wheeze	Asthma: Expiratory wheeze +/- inspiratory wheeze, maybe no breath sounds (late)
	No crackles or scattered fine basal crackles e.g. postural	LVF: May be some fine basal crackles	LVF: Crackles at bases to mid-zone	LVF: Fine crackles - full field, with possible wheeze.
				Upr Airway Obst: Inspiratory stridor
Respiratory Rate	12-16/min	16-20/min	>20	>20
Respiratory Rhythm	Regular even cycles	Asthma: May be slightly prolonged expiratory phase	Asthma: Prolonged expiratory phase	Asthma: Prolonged expiratory phase
Breathing Effort	Normal chest movement	Slight increase in normal chest movement	Marked chest movement +/- use of accessory muscles	Marked chest movement +/- use of accessory muscles, intercostal retraction +/- tracheal tugging
Skin	Normal	Normal	Pale and sweaty	Pale and sweaty, +/- cyanosis
Pulse	60-100/min	60-100/min	100-120/min	>120, bradycardia (late)
Conscious State	Alert	Alert	May be altered	Altered or unconscious