Normal and abnormal health assessment findings

Full Answer Section

• Symmetrical and Proportional: Many body parts appear balanced and in proportion (e.g., symmetrical facial features, equal limb movement).
• Absence of Distress or Discomfort: The patient appears comfortable, calm, and able to perform daily activities without undue difficulty or pain.
• Expected Appearance and Function: Organs and body systems demonstrate their typical appearance, sounds, and functions (e.g., clear lung sounds, regular heart rhythm, moist mucous membranes, full range of motion).
• Consistent with Baseline: "Normal" often refers to what is typical for that specific individual. For example, a trained athlete might have a lower resting heart rate that is normal for them, but would be considered abnormal for a sedentary person.

Examples of Normal Findings (by Body System):

• General Appearance: Alert and oriented, well-groomed, appears stated age, calm, cooperative, no acute distress.
• Vital Signs:
  • Blood Pressure: 120/80 mmHg (or within age-appropriate healthy ranges)
  • Heart Rate: 60-100 beats/minute, regular rhythm
  • Respiratory Rate: 12-20 breaths/minute, unlabored, regular depth and pattern
  • Temperature: 36.5-37.5°C (97.7-99.5°F)
• Skin: Warm, dry, intact, good turgor (skin elasticity), appropriate color for ethnicity, no lesions, rashes, or excessive pigmentation.
• Head, Eyes, Ears, Nose, Throat (HEENT):
  • Head: Normocephalic (normal size and shape), no tenderness or masses.
  • Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA); sclera white; conjunctiva pink; no discharge, redness, or excessive tearing.
  • Ears: Symmetrical, no discharge or tenderness; hearing intact to whispered voice.
  • Nose: Midline, patent nares, no discharge or tenderness.
  • Mouth/Throat: Lips pink and moist, mucous membranes pink and moist, good dentition, tongue midline with symmetrical movement, no lesions.
• Lungs/Respiratory: Clear to auscultation bilaterally (no adventitious sounds like wheezes or crackles); symmetrical chest expansion; effortless breathing.
• Heart/Cardiovascular: S1 and S2 heart sounds audible, regular rate and rhythm; no murmurs, gallops, or extra sounds; peripheral pulses (radial, pedal) 2+ (normal strength) and equal bilaterally.
• Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds in all four quadrants.
• Musculoskeletal: Full range of motion in all joints; symmetrical muscle strength (5/5); no deformities, swelling, or redness.
• Neurological: Alert and oriented to person, place, and time; clear speech; symmetrical facial movements; normal gait and balance; intact sensation.

Abnormal Health Assessment Findings

Abnormal findings, also known as unexpected findings, are observations that deviate from typical, healthy parameters. They often indicate a potential health problem, disease, injury, or a worsening of a pre-existing condition, and require further investigation and potentially intervention.

Characteristics of Abnormal Findings:

• Outside Established Ranges: Vital signs are significantly too high or too low.
• Asymmetry or Disproportion: Unequal or disproportionate body parts (e.g., facial drooping, unilateral swelling, unequal pupil size).
• Signs of Distress or Discomfort: Patient appears in pain, anxious, agitated, confused, has difficulty breathing, or shows other signs of discomfort.
• Deviations in Appearance or Function: Organs or systems show atypical appearance, sounds, or functions (e.g., abnormal skin color, adventitious lung sounds, irregular heart rhythm, palpable masses, limited range of motion).
• Inconsistency with Baseline: A significant change from the patient's usual state of health or a worsening of a chronic condition.

Examples of Abnormal Findings (by Body System):

• General Appearance: Appears acutely ill, signs of distress (e.g., grimacing, labored breathing, confusion), disoriented, agitated, unkempt.
• Vital Signs:
  • Blood Pressure: Significantly elevated (e.g., 160/95 mmHg, hypertension) or very low (e.g., 80/40 mmHg, hypotension).
  • Heart Rate: Tachycardia (>100 bpm), bradycardia (<60 bpm), irregular rhythm (e.g., atrial fibrillation).
  • Respiratory Rate: Tachypnea (>20 bpm), bradypnea (<12 bpm), shallow or labored breathing, use of accessory muscles, nasal flaring.
  • Temperature: Fever (>37.5°C) or hypothermia (<36.5°C).
• Skin: Pallor (pale), cyanosis (bluish), jaundice (yellowish), erythema (redness), diaphoresis (excessive sweating), clammy skin, lesions, rashes, poor turgor (tenting), edema (swelling, e.g., 2+ pitting edema).

Sample Answer

In healthcare, a health assessment is a systematic process of gathering information about a patient's health status. It involves both subjective data (what the patient reports, like symptoms) and objective data (what the healthcare provider observes and measures, like vital signs or physical exam findings). Differentiating between normal and abnormal findings is fundamental to clinical practice, as it guides diagnosis, intervention, and ongoing patient care.

Here's a breakdown of the differences:

Normal Health Assessment Findings

Normal findings, also known as expected findings, are observations that fall within typical, healthy parameters for an individual, considering their age, gender, medical history, and baseline health status. They indicate that the body's systems are functioning as anticipated.

Characteristics of Normal Findings:

• Within Established Ranges: Vital signs (temperature, pulse, respiratory rate, blood pressure) are within accepted healthy ranges.