Health Assessment
During a routine annual visit of a 2-year-old client, what is the
correct order the nurse should perform the tasks in a health
assessment?
Introduce yourself, ask about problems or concerns, take a history, and perform the exam.
A proper health assessment should always begin with
introductions. The nurse should introduce themselves and ask
the names and relationships of all the parties in the room. The
Health Insurance Portability and Accountability Act (HIPAA)
applies to the nursing care of children and no assumptions
should be made about any aspect of nursing care. After
introductions, it is customary to ask the primary caregiver if it
is permissible for everyone in the room to hear about
protected health information that may be discussed during
the visit.
Next, the nurse should ask about specific problems or
concerns the caregiver may have in order to perform a
thorough physical exam focusing on the areas of concern. A
thorough history is needed for accurate assessment and
documentation and to assist with the plan of care.
Lastly, the nurse should perform the physical assessment,
making sure to use age and developmentally appropriate
language.
Toddlers can be suspicious of strangers and anyone in
scrubs or a lab coat. The assessment should be performed
with this in mind and the nurse may need to alter assessment
strategies in order to gain cooperation from the toddler.
Position the toddler supine, sitting, or standing on or by the
caregiver, inspect the body through play (i.e., count fingers,
tickle toes) using minimal contact initially, introduce
equipment slowly, auscultate, percuss, palpate whenever
quiet, and perform traumatic procedures last.
Pediatric Physical Assessment
The physical examination should include the following:
This study source was downloaded by 100000897367967 from CourseHero.com on 12-09-2025 08:21:08 GMT -06:00
https://www.coursehero.com/file/252981679/NR-328-Week-3-Edapt-Health-Assessmentdocx/
, Growth Curve
The child’s weight and height should be compared to normal
values on the growth curve. Children with cardiac alterations
tend to be small for their age. Many of these children fail to
thrive.
Vital Signs
Vital signs should be assessed and may vary with age. Heart
rates will decrease as the child ages. Blood pressure
differences in extremities can indicate a defect known as
coarctation of the aorta.
Heart Sounds
Auscultation of heart sounds should be completed in both a sitting and reclining position. S1 and
S2 heart sounds should be clear and crisp. S1 is louder at the apex of the heart while S2 is louder
near the base of the heart. Sinus arrhythmias that are associated with respirations are common.
Circulation
Assessing for cyanosis, capillary refill time, neck veins, edema, and clubbing of fingers should
be performed. In a child with cardiovascular alterations, cyanosis will first appear as
circumoral, in nailbeds, buccal, and around the eyes. Clubbing will appear only after the child
has had long- term cardiac alterations resulting from long-term hypoxia.
Pulses
Palpation of pulses should be bilaterally equal. Pulse locations
and expected findings in children and adolescents are the
same as those in the adult population.
• The radial pulse is difficult to palpate accurately in
children younger than 2 years of age because the
blood vessels lie close to the skin surface and are
easily obliterated.
• Infants and young children are often nervous or fearful,
causing the heart rate to elevate; therefore, the nurse
should listen to the heart a few minutes before counting
the pulse.
• For infants and children, auscultate the apical
pulse (4th intercostal space at the left
midclavicular line) with the stethoscope for a full
minute.
• In infants, brachial, temporal, and femoral pulses should
be palpable, full, localized, and compared bilaterally at the
same time while assessing strength and regularity.
• Pulses that are weaker in the legs and bounding in the
This study source was downloaded by 100000897367967 from CourseHero.com on 12-09-2025 08:21:08 GMT -06:00
arms can suggest coarctation of the aorta.
https://www.coursehero.com/file/252981679/NR-328-Week-3-Edapt-Health-Assessmentdocx/
During a routine annual visit of a 2-year-old client, what is the
correct order the nurse should perform the tasks in a health
assessment?
Introduce yourself, ask about problems or concerns, take a history, and perform the exam.
A proper health assessment should always begin with
introductions. The nurse should introduce themselves and ask
the names and relationships of all the parties in the room. The
Health Insurance Portability and Accountability Act (HIPAA)
applies to the nursing care of children and no assumptions
should be made about any aspect of nursing care. After
introductions, it is customary to ask the primary caregiver if it
is permissible for everyone in the room to hear about
protected health information that may be discussed during
the visit.
Next, the nurse should ask about specific problems or
concerns the caregiver may have in order to perform a
thorough physical exam focusing on the areas of concern. A
thorough history is needed for accurate assessment and
documentation and to assist with the plan of care.
Lastly, the nurse should perform the physical assessment,
making sure to use age and developmentally appropriate
language.
Toddlers can be suspicious of strangers and anyone in
scrubs or a lab coat. The assessment should be performed
with this in mind and the nurse may need to alter assessment
strategies in order to gain cooperation from the toddler.
Position the toddler supine, sitting, or standing on or by the
caregiver, inspect the body through play (i.e., count fingers,
tickle toes) using minimal contact initially, introduce
equipment slowly, auscultate, percuss, palpate whenever
quiet, and perform traumatic procedures last.
Pediatric Physical Assessment
The physical examination should include the following:
This study source was downloaded by 100000897367967 from CourseHero.com on 12-09-2025 08:21:08 GMT -06:00
https://www.coursehero.com/file/252981679/NR-328-Week-3-Edapt-Health-Assessmentdocx/
, Growth Curve
The child’s weight and height should be compared to normal
values on the growth curve. Children with cardiac alterations
tend to be small for their age. Many of these children fail to
thrive.
Vital Signs
Vital signs should be assessed and may vary with age. Heart
rates will decrease as the child ages. Blood pressure
differences in extremities can indicate a defect known as
coarctation of the aorta.
Heart Sounds
Auscultation of heart sounds should be completed in both a sitting and reclining position. S1 and
S2 heart sounds should be clear and crisp. S1 is louder at the apex of the heart while S2 is louder
near the base of the heart. Sinus arrhythmias that are associated with respirations are common.
Circulation
Assessing for cyanosis, capillary refill time, neck veins, edema, and clubbing of fingers should
be performed. In a child with cardiovascular alterations, cyanosis will first appear as
circumoral, in nailbeds, buccal, and around the eyes. Clubbing will appear only after the child
has had long- term cardiac alterations resulting from long-term hypoxia.
Pulses
Palpation of pulses should be bilaterally equal. Pulse locations
and expected findings in children and adolescents are the
same as those in the adult population.
• The radial pulse is difficult to palpate accurately in
children younger than 2 years of age because the
blood vessels lie close to the skin surface and are
easily obliterated.
• Infants and young children are often nervous or fearful,
causing the heart rate to elevate; therefore, the nurse
should listen to the heart a few minutes before counting
the pulse.
• For infants and children, auscultate the apical
pulse (4th intercostal space at the left
midclavicular line) with the stethoscope for a full
minute.
• In infants, brachial, temporal, and femoral pulses should
be palpable, full, localized, and compared bilaterally at the
same time while assessing strength and regularity.
• Pulses that are weaker in the legs and bounding in the
This study source was downloaded by 100000897367967 from CourseHero.com on 12-09-2025 08:21:08 GMT -06:00
arms can suggest coarctation of the aorta.
https://www.coursehero.com/file/252981679/NR-328-Week-3-Edapt-Health-Assessmentdocx/
