Chapter 4: Communication & Physical Assessment: Child & Family

Communication & Physical Assessment: Child & Family begins by establishing guidelines for interviewing parents and caregivers, stressing the importance of a private setting, confidentiality, and the use of open-ended questions to elicit accurate health histories. The text details developmentally appropriate communication strategies for children: using nonverbal reassurance for infants, avoiding literal interpretations with egocentric toddlers and preschoolers, providing functional explanations for school-age children, and ensuring privacy to build trust with adolescents. Creative techniques such as storytelling, play, and "I" messages are highlighted as methods to overcome verbal barriers. The comprehensive health history is outlined to include birth history, immunization status, dietary intake (assessed via 24-hour recall or food diaries), and a detailed review of systems. Nutritional assessment is further supported by clinical examination and anthropometry, differentiating between recumbent length for infants and standing height for children over 24 to 36 months, alongside weight, head circumference, and BMI calculations to monitor growth velocity. The chapter then transitions to the physical examination, advocating for "atraumatic care" by altering the standard head-to-toe sequence to accommodate the child's developmental level—such as auscultating the heart and lungs when an infant is quiet and reserving distressing procedures like otoscopy for last. Vital sign measurement is nuanced for pediatrics: apical pulses are preferred for young children; respirations are observed for abdominal movement in children under 7 years; and blood pressure cuffs must have a bladder width of approximately 40% of the arm circumference to ensure accuracy. The physical assessment is broken down by body system, identifying normal variations and potential abnormalities. Key assessments include inspecting the skin for turgor and lesions; palpating fontanels (noting the anterior fontanel closes between 12 and 18 months); and evaluating the eyes for strabismus using the corneal light reflex and cover tests. The ear examination requires specific positioning—pulling the pinna down and back for children under 3 years, and up and back for older children. Cardiac assessment focuses on differentiating S1 and S2 sounds, identifying physiologic splitting, and grading murmurs, while respiratory assessment involves identifying vesicular, bronchovesicular, and bronchial breath sounds. The abdominal exam prioritizes inspection and auscultation before palpation to avoid altering bowel sounds, checking for hernias and organomegaly. Musculoskeletal checks include screening for scoliosis and evaluating gait variances like genu varum (bowleg) and genu valgum (knock-knee). Finally, the neurologic assessment covers cerebellar function, deep tendon reflexes, and cranial nerve testing, utilizing games to elicit cooperation from younger patients.