Professional Documents
Culture Documents
A = Appearance (skin color) P = Pulse (heart rate) G = Grimace (reflex irritability) A = Activity (muscle tone) R= Respiration
(respiratory effort)
0 Points
Absent Absent Flaccid, Limp Unresponsive Cyanosis
1 Point
Under 100 Irregular, Weak Some flexion
2 Points
Over 100 Crying, Vigorous Active flexion, good motion
Frown/Grimace Active motionw/ stimulation cry, cf. sneeze Acrocyanosis Completely Pink
Identifies need for immediate intervention Score 2 0r less = immediate resuscitation Score 3 to 6 = some assistance, usually stimulation, suctioning, oxygen Score 7 or more = routine care and observation
Assess infants recovery from depression Also assess effectiveness of intervention Score 7 to 10 = Few, if any, supportive measures Score 4 to 6 = Mild to moderate asphyxia; suctioning, oxygenation, mech ventilation Score 0 to 3 = Full cardiopulmonary resuscitation
SILVERMAN SCORE
Looks at level of respiratory distress Scoring in 5 areas, range from 0 to 2
(continued)
0 to 3 = no respiratory distress to mild distress 4 to 6 = moderate respiratory distress 7 to 10 = severe respiratory distress
Dr. Dubowitz and co-workers (Early 1970s) 10 external characteristics 11 Neuromuscular signs
New Ballard Score (NBS)
to +4 or +5
Skin - transparent to leathery, cracked Lanugo - none to mostly bald, upper back only Plantar Surface - little or no creases to creases over entire sole Breast - imperceptible to full areola
Posture & extremities / muscle tone: Posture - hypotonic w/ arms & legs extended to arms & legs flexed w/ recoil Square Window (wrist) - greater than 90* to 0* Arm Recoil - none to full recoil w/ angle < 90* Knee Joint Angle (popliteal) - from 180* to less than 90*
SCORING SYSTEM
25 30 35 40 45 50 34 wks 36 wks 38 wks 40 wks 42 wks 44 wks
Vernix
grayish white cheeselike substance composed of
sebaceous gland secretions lanugo shed epithelial cells
Preterm covered Term has very little, only in body creases Post-term has none
Nails
present and cover nail bed all ages may be especially long in post-term
Growth Assessment
Colorado intrauterine growth curve
Birth weight Length Head circumference Data from Colorado infants 1948 to 1961
= AGA
Score below the 10th percentile
= SGA
VITAL SIGNS
RESPIRATORY RATE
HEART RATE
BLOOD PRESSURE
TEMPERATURE
RESPIRATORY RATE
Normal = 30 to 60, variable Periodic Breathing = respiration
HEART RATE
Normal newborn = 110 to 160 Determined by auscultation Transient increases w/ agitation Persistent tachy associated w/ congenital
heart defects Brady associated w/ significant apnea Apical impulse - normal vs. abnormal location
BLOOD PRESSURE
Normal Ranges:
Low birth weight = 50/35 mmHg. Mid b.w. above 2000 gm. = 60/35 mmHg. High b.w. above 3000 g. = 65/40 mmHg.
Assessed with doppler and cuff Peripheral pulses for indirect assessment
TEMPERATURE
Normal core = somewhat variable Rectum is best assessment of core Axilla, usually lower but may be falsely high
Skin Temp
Allow continual measurement Pt. Care not interfered Maintained about 36.5 degrees (C) Minimize O2 consumption
Tachypnea Cyanosis Nasal Flaring - Silverman score Expiratory Grunting - Silverman score Retractions - Partially Silverman score
Intercostal = between ribs Supraclavicular = above clavicles Subcostal = below rib margins Suprasternal = top margins of sternum Xiphoid = bottom margins at xiphoid process
= periods of no respiration for at least 20 seconds Or periods of absence of respiration accompanied by bradycardia (HR < 100)
Chest Auscultation
Rales
crackles short, interupted sounds usually during inspiration associated with
HMD Pulmonary Edema Pneumonia
Rhonchi
changes in pitch narrowing of airways
secretions swelling foreign matter smooth muscle spasm
Eyes
Size -Shape -Position
-Patency of Nasal Pasages -Size of tongue & jawbone
Nose
Size -Shape
Mouth
Lips -Hard/Soft Palate
Color
Pulses