What is a normal assessment?

A normal assessment is a process of evaluating an individual's physical, mental, emotional, and social well-being. This can include gathering information about a person's medical history, conducting physical examinations, and assessing their mental health through interviews or questionnaires. The goal of a normal assessment is to identify any potential health issues or concerns and develop a plan for treatment or intervention.

Normal Physical Assessment

General

- Alert and oriented x4 (person, place, time, situation)
- Cooperative and calm demeanor
- No acute distress

Vital Signs

- Temperature: 97.6-99.6°F (36.4-37.6°C)
- Pulse: 60-100 bpm, regular rhythm
- Respirations: 12-18 bpm, unlabored
- Blood pressure: 110-140/60-90 mmHg

Head, Eyes, Ears, Nose, Throat (HEENT)

Head:
- Normocephalic (symmetrical)
- No scalp lesions or tenderness
- Hair evenly distributed, no alopecia

Eyes:
- Pupils equal, round, and reactive to light
- Conjunctivae clear and pink
- Sclerae white
- Corneas clear
- Extraocular movements intact

Ears:
- Auricles symmetrical
- Tympanic membranes pearly gray, translucent

Nose:
- Nasal mucosa pink and moist
- No discharge
- Septum midline

Throat:
- Oropharynx pink and moist
- Tonsils not enlarged or inflamed
- No lesions or exudate

Neck

- Supple muscles
- No thyromegaly or lymphadenopathy
- Trachea midline

Chest

- Thorax symmetrical
- Breathing excursions equal bilaterally
- Lungs clear to auscultation
- No wheezes, rales, or rhonchi

Heart

- Regular heart rhythm
- No murmurs, gallops, or clicks
- Point of maximal impulse (PMI) at 5th intercostal space, midclavicular line

Abdomen

- Soft and non-tender
- No palpable masses or organs
- Bowel sounds present

Extremities

- Warm and well-perfused
- No edema
- Capillary refill <2 seconds
- Joints without swelling or tenderness
- Range of motion intact

Neurological

- Glasgow Coma Scale (GCS) score of 15
- Cranial nerves intact
- Motor and sensory function normal
- Reflexes present and symmetrical

Genitourinary

Male:
- Genitalia unremarkable
- No hernias or masses

Female:
- Genitalia external, no discharge or lesions

Musculoskeletal

- Normal range of motion
- No muscle weakness or atrophy
- Gait steady and balanced

Psychiatric

- Mood and affect appropriate
- Thought process clear and organized
- No signs of psychosis or mania

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