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Vital Signs

Temperature Pulse Blood Pressure Respiration Pain (considered the 5th vital sign)

Vital Signs (VS) are the most important measurements you will obtain when you evaluate or assess a client’s condition. A change in vital signs may indicate a change in health.

Vital Signs

Vital signs in pediatrics include - temperature- heart rate(pulse)- blood pressure - respiration- weight- height- head circumference.Height, weight, and head circumference should be plottedon a growth curve graph.

Vital Signs

Frequency of vital signs Vital signs are assessed at least every 4 hours - in hospitalized patients with elevated temperatures - low or high blood pressures - changes in pulse rate or rhythm - respiratory difficulty as well as in patients who are taking

medications that effect cardiovascular or respiratory function - who had a surgery.

Infant Toddler School-Age Adolescent

Heart Rate 120-160 80-130 70-110 60-100

Respiratory Rate

25-40 20-35 15-25 10-20

Systolic blood pressure

60-90 70-100 90-110 95-130

Diastolic blood pressure

30-55 45-65 50-70 60-80

Normal Vital Signs in Childhood

Heart rate gradually decreases from about 150 beats per minute in newborns to normal adult values of 60-100 by age 12. Heart rate goes up or down at approximately 10% per degree Celsius and 5% per degree Fahrenheit.

Temperature

Temp or Fever ?• Temperature – the measurement of heat in the body.• Fever- the measurement of heat in the body that is above normal for the individual.

Fever – a defense mechanism• Indicator of disease in body• Pathogens release toxins• Toxins affect hypothalamus• Temperature is increased• Rest decreases metabolism and heat production by the body

Temperature

Patterns of fever

• SUSTAINED- remains above normal with little change• RELAPSING – periods of febrile episodes interspersed with acceptable temp values• INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern)• REMITTENT—fever spikes and falls w/o a return to normal temp values

Patterns of fever

A. Fever continuesB. Fever continues to abrupt onset and remissionC. Fever remittentD. Intermittent feverE. Undulant feverF. Relapsing fever

Temperature Body temperature reflects the balance between the heat

produced and the heat lost from the body, and is measured in heat units called degrees. There are two kinds of body temperature:

Core temperature is the temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity; it remains relatively constant.

Surface temperature is the temperature of the skin, the subcutaneous tissue, and fat. It rises and falls in response to the environment. When the amount of heat produced by the body equals the amount of heat loss, the person is in heat balance.

TTemperatureemperature

• Normal core temperature : 37ºC (98.6ºF) + 0.8• diurnal variation = 0.6 - 1.1ºC• maximum temperature ~ 4 - 6 pm.• Oral - axilla temp < 1ºC • Rectal - oral temp < 1ºC (generally 0.4°C (0.7°F) higher than

oral readings)• Tympanic membrane ~ oral temperature (not reliable for < 3 year old children): underestimate core temp by 0.5o C• Axillary temp underestimate core temp 1o C• The standard definition of fever is a rectal temperature of >

100.4°F (38.0°C).

Temperature

A number of factors affect the body's heat production:• BMR(Basal Metabolic Rate) is the rate of energy utilization in

the body required to maintain essential activities such as breathing.

• Muscle activity; including shivering, increases the metabolic rate.

• Thyroxine output; increased thyroxine output increases the rate of cellular metabolism throughout the body.

• Epinephrine, norepinephrene, and sympathetic stimulation/stress response. These hormones immediately increases the rate of cellular metabolism in many body tissues

• Fever; fever increases the cellular metabolism rate and thus increases the body's temperature further.

Temperature

Factors affecting body temperature:

• Circadian Rhythms; predictable fluctuations in measurement of body temperature and blood pressure such as body temperature is usually lower in the morning than in the evening.

• Age; the body temperature of infants and children changes more rapidly in response to both heat and cold.

• Hormones; women tend to have more fluctuations in body temperature than men as a result of hormones changes

Temperature

Factors affecting body temperature:• Stress; the body respond to both emotional and physical

stress as a threat increasing the production of epinephrine and nor epinephrine as a result the metabolic rate increases raising the body temperature

• Environmental temperature; we are responding to a change in environment either by wearing or less clothes.

• Exercise, hard work or strenuous exercise can increase body temperature.

TemperatureFeverrectal temperature >= 38.0o C (100.4o F )

Pathophysiology: 3 causes• Raising of hypothalamic set point in CNS Infection, collagen vascular disease, malignancies lowered by antipyretic medication and removing heat• Heat production exceeding heat loss salicylate overdose, hyperthyroidism, environmental heat• Defective heat loss ectodermal dysplasia, heat stroke, poisoning with certain

drugs

Mechanism of fever productionMechanism of fever production Exgenous Pyrogens

Viruses Endotoxin Bacteria Ag-Ab complexes

Fungi DrugsAntigen+Sensitized Phagocytic LeukocytesT-Cells

MonocytesMacrophagesNeutrophils

Interleukin-1 Interleukin-1

lymphocyte-activating endogenous pyrogen

Interleukin-2 T-Cell Preoptic Anterior Hypothalmic Nuclei

Proliferation ofHelper T-Cells Prostaglandins

Fever

Interleukin-1

Phospholipids phospholipase A2

Arachidonic acid Leukotrienes lipogenase

Cyclo-oxygenaseEndoperoxides

Prostacyclins Prostaglandins Thromboxanes (PGE-2)

Fever

Heat is produced by• Metabolism• Increased muscle activity• Vasoconstriction• External sources

Heat is lost by• Vasodilation• Convection• Radiation• Conduction• Evaporization

Mechanism of heat loss:

Radiation; the transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form infrared rays.

Conduction; is the transfer of heat from one molecule to a molecule of lower temperature such as the body transfers heat to an ice pack causing the ice to melt.

Vaporization; the conversion of a liquid to vapor such as body fluid in the form of perspiration and insensible loss is vaporized from the skin.

Convection is the dispersion of heat by air currents. The body usually has a small amount of warm air adjacent to it. This warm air rises and is replaced by cooler air.

 

TemperatureFeverThe signs and symptoms of fever: loss of appetite, headache, hot, dry skin, flushed face, thirst and general malaise. Young children or other people with high fevers may experience periods of delirium or seizures.

Nursing Interventions for Client's with fever:• Monitor vital signs• Assess skin color and temperature• Monitor WBC, HCT, and other laboratory reports for

indications of infection or dehydration

TemperatureNursing Interventions for Client's with fever:• Remove excess blanket when the client feels warm, but

provide extra warmth when the client feels chilled.• Measure intake and output• Provide adequate nutrition and fluid• Reduce physical activity to limit heat production.• Administer antipyretic• Provide oral hygiene to keep the mucous membrane moist.• Provide a tepid sponge bath to increase heat loss through

conduction.• Provide dry clothing and bed linens.

Temperature

Fever: Treatment• Antipyretics: lower the central set point - inhibit cyclo-oxygenase enzyme, prevent synthesis of prostaglandin- do not interfere with immune response to infection

Doses:• Acetaminophen: 15 mg/kg every 4 hours• Ibuprofen: 10 mg/kg every 6-8 hours

Temperature

• adequate hydration − fever can cause excessive heat loss − better heat disipation with adequate intravascular volume − careful not to overhydrate and cause hyponatremia• comfortable surroundings: temperature 72o F (22o C)• not bundled in extra clothing or blankets• sponging with tepid water − temperature around 80o F (27o C) − ice baths or alcohol should be avoided: lead to shivering which may increase body temperature and is uncomfortable

Temperature

Differential diagnosis of acute fever• Upper Respiratory Tract Disease • Viral respiratory tract disease • Otitis media • Sinusitis• Lower Respiratory Tract Disease • Bronchiolitis • Pneumonia• Gastrointestinal Disorders • Bacterial gastroenteritis • Viral gastroenteritis

Temperature

• Musculoskeletal Infections • Cellulitis • Septic arthritis • Osteomyelitis• Urinary Tract Infections• Bacteremia• Meningitis

Temperature

Hypothermia a core body temperature below the lower limit of normal. The three physiologic mechanisms of hypothermia are:• Excessive heat loss• Inadequate heat production to counteract heat loss• Impaired hypothalamic thermoregulation

Temperature

The clinical signs of hypothermia:– Decreased body temperature, pulse, and

respiration– Severe shivering– Feelings of cold and chills– Pale, cool skin– Hypotension– Decreased urinary output– Lack of muscle coordination– Disorientation– Drowsiness progressing to coma– Frostbite(nose, fingers, toes)

Temperature

Nursing Interventions for Client's with hypothermia» Provide a warm environment» Provide dry clothing» Apply warm blanket» Keep limbs close to body» Cover the client's scalp with a cap » Supply warm oral or intravenous fluids» Apply warming pads

Temperature

• Temperature Sites– Oral – within the mouth or under the tongue.– Axillary – in the armpit.– Tympanic – in the ear canal.– Rectal – through the anus, in the rectum.– Other sites include on the skin or in the blood.

Temperature

Assessing Body Temperature The four most common sites for measuring body temperature

are oral, rectal, axillary, and the tympanic membrane and the skin.

Orally: It reflects changing body temperature more quickly than

the rectal method. Oral thermometers may have long, short, or rounded tips

Temperature

Contra indication of oral temperature:• Breathing is difficult or rapid• Can't close mouth for any reason• Breathing through mouth• Mouth is inflamed• Confused or comatose• Infant or young children• Oral surgery/ broken jaw• Unconscious/agitated people

Temperature

Rectally; are considered to be very accurate.

Contra indication of rectal temperature• Diarrhea• Rectal surgery • Clotting disorders• Hemorrhoids "pile"

Temperature

Axillary; is the preferred site for measuring temperature newborn because it is accessible and offers no possibility rectal perforation.

Contraindication of axillary temperature• Thin patient• Local inflammation• Unconsciousness, shocked patients• Constricted peripheral blood vessels.

Temperature

Tympanic membrane; nearby tissue in the ear canal because the membrane has an abundant arterial blood supply.

Temperature

Temporal artery thermometer are most useful for infants and children where a more invasive measurement is notnecessary.

Temperature

Temperature scalesThe body temperature is measure in degreed on two scales:

Celsius (centigrade) and Fahrenheit.C= (Fahrenheit temperature – 32) * 5/9F = (Celsius temperature * 9/5) +32

Temperature

• Types of Thermometers– Electronic

Thermometers• Measure

temperature through a probe at the end of the device.

• Hold as close as possible to the area where you wish to measure the temperature.

Temperature

• Types of Thermometers (cont.)– Glass Thermometers

• Mercury rises in a glass tube until its level matches the temperature.

Bulb shapes– Long tip – for oral use. – Security tip – for oral and rectal use.– Rounded tip – for rectal

Temperature

• Types of Thermometers (cont.)– Thermometer Handles

• Blue – oral and axillary.• Red – rectal.

– Use disposable plastic covers to prevent contamination.

Temperature

Reading a thermometer

Heart Rates(Pulse)

Age Normal Range (Resting)• Premature 120-170• 0-3 months 100-150• 3-6 months 90-120• 6-12 months 80-120• 1-3 years 70-110• 3-6 years 65-110• 6-12 years 60-95• Over age 12 55-85

PulseA wave of blood flow created by a contraction of the heart.

Pulse SitesA. TemporalB. FemoralC. PoplitealD. Posterior tibialE. CarotidF. BrachialG. RadialH. Dorsalis pedis

A.

B.

D.

E.

F.

C. G.

H.

Pulse

• Pulse sites – Radial pulse – located

inside the wrist, near the thumb.

– Brachial pulse – found in the antecubital space of the arm (the bend of the elbow) in adults.

– Apical pulse – auscultated with a stethoscope on the chest wall. The pulse is found at the apex of the heart.

PulsePulse Sites– Temporal; passes over the temporal bone of the head. The site

is superior and lateral to the eye.– Carotid; at the side of the neck between the trachea and the

sternocleiodomastoid muscle.– Apical; at the apex of the hearty. About 8cm to the left of the

sternum and at the fourth and sixth intercostals space.– Brachial; at the inner aspect of the biceps muscle of the arm– Radial; on the thumb side of the inner aspect of the wrist– Femoral; alongside the inguinal ligaments– Popliteal; behind the knee– Posterior tibial; on the medial surface of the ankle– Pedal “dorsalis pedis”; over the bones of the feet

Memeriksa denyut arteri radialis

Palpasi arteri radialis dan arteri femoralis bersamaan. Denyut femoralis yang lebih lambat menunjukkan adanya

aortic coarctation

Pulse

Factors affecting pulse:• Age; as age increases, the pulse rate gradually decreases.• Gender, male’s pulse rate is slightly lower than the female’s.• Exercise; the pulse rate normally increase with activity• Fever; the pulse rate increases in response to the lowered

blood pressure that results from peripheral vasodilatation associated with elevated temperature and because of the increased metabolic rate.

PulseFactors affecting pulse:• Medications; some medications decrease the pulse rate, and

others increase it such as digitalis decrease the heart rate.• Hypovolemia; loss of blood from the vascular system

normally increase pulse rate. Stress; in response to stress, sympathetic nervous system stimulation increases the overall activity of the heart.

• Position change; when the person is sitting or standing, blood usually pools in dependent vessels of the venous system.

• Pathology; certain diseases such as some heart conditions or those with impair oxygenation can alter the resting pulse rate.

PulseCharacteristics of the Pulse- Pulse Rate

• Assessed as beats per minute, or BPM. • Counted for 15, 20, 30, or 60 seconds.• Tachycardia – a pulse rate faster than normal. • Bradycardia – a pulse rate slower than normal.

• An elevated heart rate is seen in infections, hypovolemia, hyperthyroidism, and anxiety.

• A rule of thumb is that the heart rate increases by 10/minute for each 1 degree of temperature Centigrade.

• Bradycardia is seen in hypertension, increased intracranial pressure, certain intoxications, or other hypometabloic states.

• It is best to examine an infant’s heart first during the exam.

PulseRhythmRhythm

RegularRegular

IrregularIrregular

- Pulse Rhythm – the pattern of the heartbeats.• A client with an irregular heartbeat (arrhythmia or dysrhythmia) must be measured a full minute to determine the average rate.•When documenting pulse rhythm, record as regular or irregular.

Pulse

– Pulse volume, or strength of the pulse, can be measured with the following scale:

• 0 – absent, unable to detect.• 1 – thready or weak, difficult to palpate, and easily

obliterated by light pressure from fingertips.• 2 – strong or normal, easily found and obliterated by

strong pressure from fingertips.• 3 – bounding or full, difficult to obliterate with

fingertips.• A thready or weak pulse may indicate decreased

circulation. A bounding pulse may indicate high blood pressure.

Pulse

• Bilateral Presence – pulses should be found within the same areas on both sides of the body and have the same rate, rhythm, and volume.

Blood pressure

• Blood pressure (BP) is the pressure or tension exerted on the arterial walls as blood pulsates through them.

• Systolic blood pressure (SBP) – pressure exerted on the arteries during the contraction phase of the heartbeat.

• Diastolic blood pressure (DBP) – the resting pressure on the arteries as the heart relaxes between contractions.

Blood pressure

• Expected Blood Pressure Values– Expected SBP – 100 to 140 mm Hg.– Expected DBP – 60 to 90 mm Hg.– Hypotension – when the blood pressure drops below

expected levels. – Hypertension – high blood pressure.– Prehypertension – classified by the American Heart

Association as SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg.

Blood pressure

• Sites for Blood Pressure Assessment– Brachial – taken on the upper arm; most common site.– Radial – taken on the lower arm; possible site for infants

or clients who have very large upper arms.– Popliteal – taken on the thigh.– Dorsalis pedis and posterior tibial – taken on the lower

leg.

• Equipment for Measuring Blood Pressure– Blood pressure is measured using a sphygmomanometer,

also called a BP cuff, or cuff.

Blood pressure

• Equipment for Measuring Blood Pressure

– Types of Sphygmomanometers• Mercury – has a calibrated

glass tube containing mercury.

• Aneroid – has a calibrated dial with a needle that points to numbers on the face of the dial.

• Electronic – uses a digital display and usually includes the pulse rate.

Mengukur tekanan darahmenggunakan sphygmo-manometer dan stetoskop.

Cuff sphygmomanometerdipasang pada lengan atas yang bebas dari pakaian. Letak lengan atas sejajar dengan letak jantung.

Blood Pressure

• Blood pressure must be measured with a cuff wide enough to cover at least 1/2 to 2/3 of the extremity and its bladder should encircle the entire extremity.

• A narrow cuff elevates the pressure, while a wide cuff lowers it.

• Systolic hypertension is seen with anxiety, renal disease, coarctation of the aorta, essential hypertension, and certain endocrine abnormalities.

• Diastolic hypertension occurs with endocrine abnormalities and coarctation of the aorta.

• Hypotension occurs in hypovolemia and other forms of shock.

Blood Pressure

Blood pressure is referred to the force of the blood against arterial walls. Maximum blood pressure is exerted on the walls of arteries when the left ventricles of the heart pushes blood through the aortic valve into the aortas during contraction, the highest pressure thus called systolic pressure.

• Diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure, then, is the lower pressure present at all times within the arteries. The differences between the two called the pulse pressure

Blood Pressure

Determination of blood pressure

• Pumping action of the heart; when the pumping action of the heart is weak, less blood is pumped into arteries "lower cardiac output", and the blood pressure decreases.

• Peripheral vascular resistance; peripheral vascular can increase blood pressure. The diastolic pressure especially is affected. Some factors that create resistance in the arterial system are the capacity of the arterioles, the compliance of the arteries, and the viscosity of the blood

Blood Pressure

• Blood volume; when the blood volume decreases as a result of hemorrhage, the blood pressure decreases because of the decreased fluid in the arteries.

• Blood viscosity; blood pressure is higher when the blood is highly viscous "thick" that is, when the proportion of RBC to the blood plasma is high.

Blood Pressure

Factors affecting Blood Pressure

• Age; the pressure rises with age, reaching a peak at the onset of puberty, and then tend to decline.

• Exercise; physical activity increases the cardiac output and hence in blood pressure; thus 20-30 minutes of rest following exercise is indicated before the resting blood pressure can reliably assessed.

• Stress; stimulation of the nervous system increases cardiac output and vasoconstriction of the arterioles, however severe pain can decrease blood pressure greatly by inhibiting the vasomotor center and provide vasodilatation

• Race (African American males over 35 years have higher BP than European American males)

Blood Pressure

• Gender; after puberty, female usually have lower blood pressure than males at the same age. After menopause the female has higher blood pressure than males

• Medications• Obesity; predispose to high blood pressure• Diurnal variations; pressure is usually lowest early in the

morning when metabolic rate is low.• Disease process; any condition affecting the cardiac output,

blood volume, blood viscosity, and compliance of the arteries has a direct effect on the blood pressure.

Blood Pressure

Hypertension: an abnormally high blood pressure, over140 mm Hg systolic and 90 mm Hg diastolic. Factors associated with hypertension • Thickening of the arterial walls, which reduces the size of the

arterial lumen• Elasticity of the arteries • Lifestyle as cigarette smoking• Obesity• Lack of physical exercise• High blood cholesterol level• Continued exposure to stress

Blood Pressure

Hypotension: blood pressure below normal that is systolic reading between 85-110mm Hg. It occurs as a result of peripheral vasodilatation in which blood leaves the central body organs especially the brain and moves to the periphery

Factors associated with hypotension• Analgesics• Bleeding• Severe burn• Dehydration.

Blood Pressure

It is important to monitor hypotensive clients carefully to prevent falls. When assessing the orthostatic hypotension:

– Place the client in a supine position for 2-3 minutes– Record the client's pulse and blood pressure– Assist the client to slowly sit or stand. Support the client in

case of faintness– After one minute in the upright position, check the pulse

and blood pressure in the same site as previously– Record the results, a rise in pulse of 40 beats per minute

or a drop in blood pressure of 30mm Hg indicates abnormal vital signs.

Blood Pressure

Equipments used to assess pulse and blood pressure• Stethoscope; is used to auscultated and assess body sounds

including the apical pulse and the blood pressure• Sphygmomanometer; is used to assess blood pressure consist

of cuff, good selection of the cuff in order to obtain accurate blood pressure.

Blood pressure

Blood pressure sites

Assessing the blood pressure on a client’s thigh is indicated in these situations:– The blood pressure can not be measured on either arm

due to burn or other trauma– The blood pressure on one thigh is to be compared with

the blood pressure in the other thighBlood pressure is not measured on a particular clients’ limb in

the following situations:1) Avoid having blood [pressure in injured or an area with cast2) The client has had removal of axilla lymph node on that site3) The client has intravenous line in that limb4) The client has an arteriovenous fistula for dialysis in that limb

Respiration

• Respiration (R) is the act of breathing.

• Respiratory Rate (RR)– Observe the client’s chest movement upward and outward

for a complete minute.– Children under 7 years of age use abdominal breathing.– Auscultation with a stethoscope may be necessary on

clients who are aware that you are counting their respiratory rate.

Respiration

Respiration is controlled by (a) respiratory centers in the medulla oblongata and the pons of the brain and (b) by chemo receptors located centrally in the medulla and peripherally in the carotid and aortic bodies.

External respiration; the interchange of oxygen and carbon dioxide between the alveoli of the lungs and the pulmonary blood. Internal respiration; the interchange of these same gases between the circulating blood and the cells of the body tissues.

Respiration

Factors affecting RespirationsFactors increase the rate:

ExerciseIncrease metabolismStressIncreased environmental temperatureLowered oxygen concentration

Factors decrease respiration rate: Decreased environmental temperature Certain medications such as narcotics Increased intra cranial pressure

Respiration

Respiration depth; is generally described as normal, deep, or shallow. Deep respirations; large volume of air is inhaled and exhaled, inflated most of the lungs.

Shallow breathing involve the exchange of a small volume of air and often the minimal use of a lung tissue

Hyperventilation; refers to very deep, rapid respiration.Hypoventilation; refers to very shallow respirations

Respiratory rhythm refers to the regularity of the expirations and the inspirations .An respiratory rhythm can be described as regular or irregular.

Cheyne-stokes breathing, from very deep to very shallow breathing and temporary apnea.

Respiration

Kussmaul …….. Increased rate and depth of respiration above 20bpmRespiratory quality, usually breathing does not require noticeable effort. Dyspnea, difficult and labored breathing. Orthopnea, ability to breath only in upright sitting or standing positions.Breath sounds- Stridor, harsh sound heard during inspiration with laryngeal

obstruction- Stertor, snoring respiration usually due to a partial obstruction of the

upper airway.- Wheeze, continuous, high pitched musical sound occurring on

expiration when air moves through narrowed or partially obstructed air way.

Respiration

Secretions and coughing- Hemoptysis, the presence of blood in the sputum- Productive cough, a cough accompanied by expectorated

secretions- Nonproductive cough, a dry, harsh cough without secretions

Respiration

• Characteristics of Respiration– Rate of Respiration – the number of breaths per minute.

• Normal range is 12 to 20 breaths per minute for an adult.• Rate will vary with age and size of client.• An increased respiratory rate is called hyperventilation.• A decrease in respiratory rate and depth is called

hypoventilation.– Rhythm of Respiration – should be regular.– Quality of Respiration

• Can be shallow or deep.

Respiration

Respiratory Rate

• Newborn 30 - 75• 6 - 12 months 22 - 31• 1 - 2 years 17 - 23• 2 - 4 years 16 - 25• 4 - 10 years 13 - 23• 10 - 14 years 13 - 19• 15 + same as adult

Respiration

• Tachypnea is seen with increased activity, hypermetabolic states, fever, or respiratory distress.

• A decreased respiratory rate is seen with conditions affecting the central nervous system, including medications/toxins, congenital malformations, and other lesions.

• A variable respiratory rate, known as periodic breathing, is commonly seen in neonates but more than a 20 second pause is always abnormal.

• Cheyne-Stokes breathing is seen with brainstem abnormalities.

Oxygen Saturation

A pulse oximeter: is a non invasive device that measures a client's arterial blood oxygen saturation by means of a sensor attached to the client's finger, toe, nose, earlobe, or forehead. The pulse oximeter can detect hypoxemia before clinical signs and symptoms such as dusky skin color and dusky nailbed color.

Factors affecting oxygen saturation reading• Hemoglobin; if the hemoglobin is fully saturated with oxygen,

the saturation will appear normal even if the total hemoglobin level is low

• Circulation• Activity; shivering or excessive movement of the sensor site

may interfere with accurate reading.• Carbon monoxide poisoning.

Weight

• Decrease in weight percentile may be due to - decreased intake (malnutrition, central nervous system abnormality) - malabsorption (cystic fibrosis, IBD, celiac disease, parasitic infestation), or - increased metabolic rate (hyperthyroidism, congestive heart failure).• Increase in weight is most commonly exogenous ,but may

also be associated with certain genetic syndromes (Prader- willi).

Height

• A child’s length (lying flat on a table) is measured until 2 to 3 years of age; after that it is measured as height (standing).

• Decrease height may be familial, or may be seen in conditions affecting weight or independent of weight (Turner syndrome).

• Increase height may be familiar or associated with certain genetic and endocrine abnormalities (Cerebral gigantism).

Head Circumference

• Head circumference is routinely measured until 2 to 3 years of age.

• Microcephaly may be part of a syndrome (Rett syndrome), congenital infection (CMV), or the result of abnormal brain growth (schizencephaly).

• Macrocephaly may be familiar or may represent a pathologic state (Hydrocephalus, Canavaan disease, AV malformation).

General appearance

• Does patient appear ill ? To what degree ? • State of consciousness, or mental status• General nutrition status • Position or posture • Note characteristics that strike you on first observing the patient (e.g. severe respiratory distress, moderate jaundice, unusual face, inspiratory stridor)