NSB103 Health Assessment: Normal vs Abnormal
Normal vs Abnormal Assessment Data
Learning Objectives
- Normal vs abnormal General survey data (subjective)
- Normal vs abnormal Primary survey data (ABCDE)
- Normal vs abnormal vital signs
- Normal vs abnormal cardiovascular system assessment data
- Normal vs abnormal respiratory system assessment data
- Normal vs abnormal neurological assessment data
Defining Key Terms
- Objective assessment data: Physical data observable through senses.
- Measurements.
- Direct observation.
- Cannot be argued, measured through vital signs, tests, and physical examination.
- Subjective assessment data: Information from the patient/carer. How they are feeling, symptoms, or concerns.
- Abnormal assessment data: Deviates from normal.
- Outside normal vital sign ranges.
- Acute patient deterioration: Physiological changes, cognition, and mental state changes.
- National Safety and Quality Health Service (NSQHS) Standard 8: Recognising and Responding to Acute Deterioration.
The General Survey
- Ascertaining your impression of the person.
- Includes general health state and obvious physical characteristics.
- Forms the first part of objective data collection.
The General Survey: Physical Status Data
| Normal | Abnormal |
|---|---|
| Person’s stated age should be congruent with their apparent age. Ageing well | Not ageing well; child larger or smaller than ageStated age versus apparent age |
| Body should be symmetrical; no obvious deformity; tatoo’s/piercings (normal/cultural); should have a look of wellness (colour etc) | Visible disabilities/anomalies; distinctive markings (?normal); facial asymmetry- eg drooping- causes?General appearance |
| Muscle, body fat should be fairly evenly distributed, different types of body shapes; Body fat | BMI category- underweight, overweight, obese? Uneven weight distribution- linked to specific diseases |
| Erect posture; arms and legs in proportion to body height | Posture slumped, humpbacked, kyphosisBody conformation and posture |
| Movement and gait should be smooth and effortless; all body parts have controlled purposeful movement. | Slow movement; limping; shuffling gait; tremorsMotor activity |
| Reasonably odour free, can be dependent on type of diet; Eg foods, spicy, garlicky?- these are normal | Bad breath (halitosis) - sweet smelling breath, cigarettes, alcohol etc;Body odour- severe body odour, sweatBody and breath odours |
The General Survey: Psychological Status Data
| Normal | Abnormal |
|---|---|
| Appear awake and alert, orientated to person, place and date/time (AVPU- Alert; GCS- 15; MMSE- normal memory and function) | Altered level of consciousness; confusion, lethargy, stupor, coma; altered attention, memory, judgement; Dementia, Delirium, neurological injury etcMental status and cognitive function (level of consciousness) |
| Facial expression should be appropriate for the circumstances and should change naturally | Lack of expression, apathy; unchanging or flat facial expression, inappropriate facial expression, tremors, ticsFacial expression |
| Presents clean and neatly dressed; dressed appropriately for the weather. | Disheveled, unkempt appearance or unclean clothes; unclean, unshaven; clothes not appropriate for weatherDress, grooming, personal hygiene |
| Presents as cooperative, and pleasant | Uncooperative, hostile, tearful, unusual elation, mood swings, flat effect or mood, euphoriaMood and manner |
| Should be clear and understandable, responds to questions and commands easily. Pitch, rate, volume and content should be appropriate to circumstances | Speech that is slow, slurred, mumbled, not articulate, very loud or rapidSpeech and communication |
| Signs of distress absent, breathing effortless, face relaxed | Shortness of breath, laboured speech, wheezing, coughing, facial expressions showing painDistress |
The Primary Survey
- Systematic assessment of a patient.
- Assessing for injuries or medical conditions.
- Quick and comprehensive.
The Purpose of a Primary Survey
- Identify any abnormalities or issues/concerns.
- Identify any deterioration in your patient.
- Identify any modifications to the patient’s current care plan.
The Primary Survey: A and B
| Normal | Abnormal |
|---|---|
| Clear/patent; patient should be able to speak | Noisy breathing; obstructionAirway |
| Eupnoea; Respiration rate: 12-20 breaths per min for adult; regular; no abnormal sounds; symmetrical breathing; work of breathing- normalO2 saturations: 95-100% | Inspiration/expiration irregular; shallow breathing; use of accessory muscles; tracheal tug, nasal flaring Abnormal lung sounds on auscultation Tachypnoea/bradypnoea/apnoeaHypoxaemia; hypoxiaO2 sats <95%Breathing |
The Primary Survey: C
| Normal | Abnormal |
|---|---|
| Skin colour and temperature: normal colour for patient (absence of cyanosis); normal temperature to touch.Capillary refill: <2 seconds.Heart rate within normal range (60-100bpms for adult), regular, strong.Heart sounds normal on auscultation.Blood pressure within normal range.Lower limbs: normal colour, warmth, sensation and movement. Distal pulses present.Absence of oedema.Normal urine output. | Skin colour: central of peripheral cyanosis. Temperature: cold, clammy. Jugular venous distension. Capillary refill time > 2 seconds. Bradycardic/Tachycardic. Heart sounds abnormal eg presence of murmur. Hypotensive/Hypertensive. Lower limbs: colour abnormal (eg cyanosis), cool or hot to touch, decreased sensation (eg numb or tingling),decreased movement; oedema/pitting oedema present; distal pulses absent or weak; in one or both limbs. Urine output absent, decreased or increased.Circulation |
The Primary Survey: D and E
| Normal | Abnormal |
|---|---|
| Level of consciousness: Alert (A in AVPU).GCS: score of 15Pupil response: Pupils equal in size and response to light (PEARL), brisk constriction in response to light.Muscle strength: symmetrical in strength. | Not responsive to voice (V); not responsive to pain (P); unresponsive (unconscious) (U).GCS: score < 15 Pupils: not reacting to light, not equally reacting to light, dilated or constricted pupils. Muscle strength not symmetrical.Disability |
| Patient looks well | Patient looks unwell, sick or critical. Note treatments in progressExposure/ environment (head to toe scan) |
Glasgow Coma Scale
- Eye Opening:
- Spontaneous: 4
- To Voice: 3
- To Pain: 2
- None: 1
- Verbal Response:
- Oriented: 4
- Confused: 3
- Inappropriate Words: 2
- Incomprehensible Words: 1
- None: 1
- Motor Response:
- Obeys Commands: 6
- Localizes Pain: 5
- Withdraws (Pain): 4
- Flexion (Pain): 3
- Extension (Pain): 2
- None: 1
- Total GCS: (≤7 indicates coma)
Levels of Consciousness
- A - Alert
- V - Verbal
- P - Painful Stimuli
- U - Unresponsive
Vital Signs
Blood Pressure
| Age Group | Normal Blood Pressure | Optimal Blood Pressure |
|---|---|---|
| Adult | 120-129/80-84mmHg | Not more than 120/80mmHg |
| Older Adult | Not more 140-145/90mmHg | |
| Youth (15 years) | Female- 120-127/ 78-81mmHg; Male- 122-131/ 76-81mmHg | |
| Primary school aged child | 5 years: Female- 103-109/ 66-70mmHg Male- 104-112/ 65-70mmHg 10 years: Female- 112-118/73-76mmHg Male- 111-119/ 73-78mmHg | |
| Infant | I year: Female- 97-103/ 52-56mmHg Male- 94-103/ 49-54mmHg |
Pulse/Heart Rate
| Age Group | Normal Heart Rate (bpm) | Abnormal (Bradycardic) | Abnormal (Tachycardic) |
|---|---|---|---|
| Newborn | 100-170 bpm | <100 bpm (average 140) | >170 bpm |
| Primary school aged child | 70-115 bpm | <70 bpm (average 90-100) | >115 bpm |
| Youth/Adolescent (14 years) | 60-110 bpm | <60 bpm | >110 bpm |
| Adult | 60-100 bpm | <60 bpm (average 72) | >100 bpm |
| Older Adult | 60-100 bpm | <60 bpm (average 70) | >100 bpm |
The Primary Survey: C
| Age Group | Normal Heart Rate (bpm) | Abnormal (Bradycardic) | Abnormal (Tachycardic) |
|---|---|---|---|
| Newborn | 100-170 bpm | <100 bpm (average 140) | >170 bpm |
| Primary school aged child | 70-115 bpm | <70 bpm (average 90-100) | >115 bpm |
| Youth/Adolescent (14 years) | 60-110 bpm | <60 bpm | >110 bpm |
| Adult | 60-100 bpm | <60 bpm (average 72) | >100 bpm |
| Older Adult | 60-100 bpm | <60 bpm (average 70) | >100 bpm |
Respiration Rate
| Age Group | Normal (resps per min) | Abnormal (Bradypnoea) | Abnormal (Tachypnoea) |
|---|---|---|---|
| Newborn | 30-50 | <50 (average 40) | >50 |
| Primary school aged child | 16-20 | <16 (average 18-19) | >20 |
| Youth/Adolescent (14 years) | 14-20 | <14 (average 17) | >20 |
| Adult | 12-20 | <12 (average 18) | >20 |
| Older Adult | 15-20 | <12 (average 16) | >20 |
Temperature
| Method | Newborn (0-2) | Primary school aged child | Youth | Adult | Older |
|---|---|---|---|---|---|
| Oral | n/a | 35.5-37.5 | 36.2-37.5 | 35.5-37.5 | 35.5-37.5 |
| Axillary | 35.5-37.5 | 36.4-38 | 36.1-37.7 | 35.8-37.6 | 35.8-38 |
| Tympanic | 36.4-38 | 35.8-36.7 | 35.5-36.3 | 36.6-38 | 36.6-38 |
| Rectal | 37-38 | 36.6-38 | 36.6-38 | 36.6-38 | 36.6-38 |
Oral temperatures are averages. Temperatures will be 0.5-0.6 degrees lower when taken via axillary. Tympanic and rectal are 0.4-0.5 degrees higher than oral.
Queensland Adult Deterioration Detection System (Q-ADDS)
- A scoring system used to detect patient deterioration.
- Involves assessing:
- Respiratory Rate
- O2 Saturation
- Oxygen Delivery Method
- Blood Pressure
- Heart Rate
- Temperature
- Consciousness
- Total score determines the necessary interventions and escalations.
- Modifications can be made for patients with chronic abnormal physiology, authorized by a senior medical officer.
- Temporary modifications can also be made within specific guidelines and require careful monitoring.
- Pain and sedation assessment also included, though sedation score is not added to the Q-ADDS score.
Abnormalities of the Cardiovascular System
- Abnormal heart rhythms (arrhythmias)
- Aorta disease
- Marfan syndrome
- Congenital heart disease
- Coronary artery disease
- Deep vein thrombosis
- Pulmonary embolism
- Heart attack (myocardial infarction)
- Heart failure
- Cardiomyopathy
- Heart valve disease
- Pericardial disease
- Peripheral vascular disease/Vascular disease
- Rheumatic heart disease
- Stroke
Abnormalities of the Respiratory System
- Asthma
- Asbestosis/Silicosis
- Bronchiectasis/Bronchiolitis/Bronchitis
- Chest infection (eg RSV, pneumonia etc)
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic Fibrosis
- Emphysema
- Lung cancer
- Mesothelioma
- Pleural effusion
- Pleurisy
- Pneumothorax
- Tuberculosis
- Whooping cough (Pertussis)
Abnormalities of the Neurological System
- Classified as:
- Vascular disorders (eg stroke, haemorrhage etc)
- Infections (eg meningitis, encephalitis etc)
- Structural disorders (eg brain of spinal cord injury, Bell’s palsy etc)
- Functional disorders (eg epilepsy, neuralgia etc)
- Degeneration (eg Alzheimer disease, MS etc)
- Cancers (eg brain tumours- primary and secondary etc)
- Injuries to spinal cord and brain
- Genetic (eg Huntington’s disease)