Assessment abnormal vs normal

Assessment: Normal vs Abnormal

Page 1

Overview

  • Assessment differences between normal and abnormal findings.

Page 2: Neurological Findings

Normal Findings

  • Alert and oriented to person, place, and time.

  • Symmetrical facial expressions.

  • Clear and appropriate speech.

  • Ability to follow instructions.

  • PERRLA: Pupils are equal, round, and reactive to light and accommodation.

  • Cranial nerves: all intact.

  • Negative Romberg test.

  • Sensory function: present.

  • Inspections show intact cortical functioning.

  • Good balance with coordinated gait, equal arm swing.

  • Ability to complete finger-to-nose and rapid alternating movements.

  • Negative pronator drift test.

  • Motor strength in upper and lower extremities equal bilaterally.

  • Deep tendon reflexes intact.

Abnormal Findings

  • Not alert/oriented to person, place, or time.

  • Asymmetrical facial expressions.

  • Garbled speech.

  • Inability to follow directions.

  • Unequal PERRLA findings.

  • Sensory function impaired in one or more areas.

  • Poor balance, shuffling/asymmetrical gait.

  • Positive Romberg test.

  • Unequal strength of extremities.

  • One or more deep tendon reflexes not equal bilaterally.

  • Change in mental status: pupil responsiveness, facial drooping, slurred speech.

  • Any critical findings should be reported immediately.

Page 3: Cardiovascular Findings

Normal Findings

  • Scars: documented.

  • Apical impulse may or may not be visible.

  • Regular rhythm S1 and S2 heart sounds.

  • No indication of prior cardiac surgeries.

  • Chest anatomy appears normal on palpation.

  • Additional movements: none.

Abnormal Findings

  • New irregular heart rhythm observed.

  • Chest anatomy malformations present.

  • Apical pulse location incorrect.

  • Extra heart sounds (murmurs, S3, S4).

  • Symptomatic tachycardia (>100 bpm) or bradycardia (<60 bpm).

  • New systolic blood pressure <100 mmHg.

  • Orthostatic blood pressure changes.

  • Reported chest pain, calf pain, or worsening shortness of breath.

Page 4: Peripheral Vascular Assessment

Normal Findings

  • Skin color is uniform and appropriate for race.

  • Equal hair distribution on extremities.

  • Absence of jugular vein distention (JVD).

  • Absence of edema.

  • Skin warm and dry.

  • Pulses present and equal bilaterally.

Abnormal Findings

  • Cyanosis or pallor: indicates decreased perfusion.

  • JVD observed in upright position (30-45 degrees).

  • Rapid and unexplained weight gain.

  • Impaired movement or sensation in fingers and toes.

  • Absent, weak/thready, or bounding pulses.

  • Capillary refill >2 seconds.

  • Unilateral warmth, redness, tenderness indicating possible DVT.

Page 5: Respiratory Findings

Normal Findings

  • Work of breathing: effortless.

  • Regular breathing pattern and normal respiratory rate.

  • Symmetrical chest expansion.

  • No cyanosis or pallor.

Abnormal Findings

  • Labored breathing or irregular rhythm.

  • Increased/decreased respiratory rate.

  • Accessory muscle use.

  • Asymmetrical chest expansion.

  • Dull sounds indicating lung density issues (e.g., pneumonia).

  • Adventitious lung sounds present.

  • Decreased oxygen saturation <92%.

  • Symptoms of worsening dyspnea or decreased consciousness.

Page 6: GI and GU Findings

Normal Findings

  • Symmetrical shape and color of abdomen.

  • Intact skin, no visible lesions.

  • Absence of pain on palpation, masses.

  • Clear, pale yellow urine and absence of urinary symptoms.

Abnormal Findings

  • Asymmetrical abdomen or distension noted.

  • Skin breakdown or wounds present.

  • Pain or tenderness with palpation.

  • Dark/bloody urine, dysuria, urinary retention, or frequency.

  • Signs of dehydration present.

  • Any critical conditions should be reported immediately.