A health assessment is a systematic process of collecting and interpreting information about a patient’s health status. It involves a combination of subjective data (what the patient tells you, like symptoms) and objective data (what you observe and measure, like vital signs or physical exam findings). Differentiating between normal and abnormal findings is a crucial skill for any healthcare professional, as it guides diagnosis, intervention, and ongoing care.

Here’s a breakdown:

Normal Health Assessment Findings

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

Characteristics of Normal Findings:

• Within established ranges: Vital signs (temperature, pulse, respiration, blood pressure) fall within accepted healthy ranges.
• Symmetrical and proportional: Many body parts should appear symmetrical and in proportion (e.g., facial symmetry, equal limb movement).
• Absence of distress or discomfort: The patient appears comfortable, calm, and able to perform activities of daily living without undue difficulty.
• 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).
• Consistency with baseline: For an individual, “normal” often means consistent with their personal baseline health status (e.g., an athlete might have a lower resting heart rate that is normal for them, but would be abnormal for a sedentary person).

Examples of Normal Findings:

• General Appearance: Alert, oriented, well-groomed, appears stated age, calm, cooperative.
• Vital Signs:
  • Blood Pressure: 120/80 mmHg (or within typical ranges for age)
  • Heart Rate: 60-100 beats/minute, regular rhythm
  • Respiratory Rate: 12-20 breaths/minute, unlabored
  • Temperature: 36.5-37.5°C (97.7-99.5°F)
• Skin: Warm, dry, intact, good turgor, appropriate color for ethnicity.
• Eyes: Pupils equal, round, reactive to light and accommodation (PERRLA), sclera white, conjunctiva pink.
• Lungs: Clear to auscultation bilaterally (no adventitious sounds like wheezes or crackles), symmetrical chest expansion.
• Heart: S1 and S2 heart sounds audible, regular rate and rhythm, no murmurs or extra sounds.
• Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds in all four quadrants.
• Neurological: Oriented to person, place, and time; clear speech; symmetrical facial movements; normal gait.

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, or injury, and warrant further investigation.

Characteristics of Abnormal Findings:

• Outside established ranges: Vital signs are too high or too low.
• Asymmetry or disproportion: Unequal or disproportionate body parts (e.g., facial drooping, unilateral swelling).
• Signs of distress or discomfort: Patient appears in pain, anxious, agitated, or has difficulty breathing.
• 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, masses).
• Inconsistency with baseline: A significant change from the patient’s usual state of health.

Examples of Abnormal Findings:

• General Appearance: Appears acutely ill, signs of distress (e.g., grimacing, labored breathing), disoriented, agitated, unkempt.
• Vital Signs:
  • Blood Pressure: Significantly elevated (e.g., 160/95 mmHg) or very low (e.g., 80/40 mmHg).
  • 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.
  • Temperature: Fever (>37.5°C) or hypothermia (<36.5°C).
• Skin: Pallor (pale), cyanosis (bluish), jaundice (yellowish), erythema (redness), excessive sweating (diaphoresis), lesions, rash, poor turgor (tenting), edema (swelling).
• Eyes: Unequal pupils, sluggish reaction to light, nystagmus (involuntary eye movement), drainage, redness, scleral icterus (yellow sclera).
• Lungs: Wheezes (whistling sounds), crackles (rales), rhonchi (rumbling sounds), diminished or absent breath sounds, asymmetrical chest expansion.
• Heart: Murmurs, gallops (extra heart sounds like S3 or S4), thready or bounding pulses, absent pulses, peripheral edema.
• Abdomen: Distended, rigid, rebound tenderness, palpable masses, absent or hyperactive bowel sounds.