3 2 1 0 1 2 3
Frekuensi <8 8 9 – 17 18 – 20 21 – 29 ≥ 30
Pernapasan
x/menit
Frekuensi < 40 40 – 50 51 – 100 101 – 110 111 – 129 ≥ 130
Nadi x/menit
Tekanan ≤ 70 71 – 80 81 – 100 101 – 159 160 – 199 200 – 220 > 220
darah sistolik
(mmHg)
Tingkat Coma Stupor Samnolen Compos Apatis Acute
Kesadaran mentis confusional
state/
Delirium
Suhu Tubuh < 35oC 35.05 – 36.05 - 38 38.05 – > 38.5 oC
36oC o
C 38.5 oC
Hijau Kuning Orange Merah
0–1 2–3 4 -5 ≥6