Newborn Assessment Flashcards
APGAR Score
Heart Rate
Respiratory Rate
Muscle Tone
Reflex irritability
Colour
0-3: severe distress
4-6: moderate difficulty
7-10: min difficulty
Instantaneous assessment of a baby. checking 5 areas of assessment. All very quickly assessed: does it exist in roughly that area
Useful for describing newborn’s transition to extrauterine environment. Rapid assessment of newborn’s transition to extrauterine life using 5 signs including physiological state
5 areas of APGAR
- HR - auscultation with stethoscope or palpation of umbilical cord
- RR - based on observed movement or auscultation of resp effort
- Muscle tone - based on degree of flexion & mov’t of extremities
- Reflex irritability - based on response to stimulation
- Generalized skin colour (pallid, cyanotic, or pink.
do not predict future neurological outcome. if resus is needed, after drying and before 1 min apgar score
Frequency of Apgar Scoring
1 min, 5 min, 10 min (if < 7 at 5 min)
Frequency of Apgar Scoring
1 min, 5 min, 10 min (if < 7 at 5 min)
Initial Newborn Physical Assessment - Immediate care after birth
- CNS
- Cardio
- Resp
- Skin
- Ears, eyes, nose, throat
- GU
- GI
- general appearance - colour ( pink/acrocyanosis), alert, active
- CNS - moves 4 extremities, tone, symmetrical features, moro (startle) reflex, rooting/sucking, grasping, anterior fontanelle soft and flat
- Cardio - HR auscultation, no murmurs, pulses strong/equal, cap refill < 3 sec
- Resp - auscultation (clear/min crackles, RR, 60/min, non-laboured effort, chest expansion symmetrical, absence of nasal flaring/grunting/retractions)
- Skin - document lesions/abrasions, birthmarks, caput/moulding
- Eyes, ears, nose, and throat - eyes clear, palate intact, nares patent, ears correct alignment
- GU - mare urethral opening at tip of penis, testes descended. female labia minora/majora intact)
- GI - abdomen soft, no distension, cord attached & clamped, anus patent
Airway maintenance
Adequate O2 supply requirements
Maintain Body temp
Eye Prophylaxis
Vit K
- clear airway
- effective establishment of respirations
- adequate circulation, perfusion, effective cardiac function
- adequate thermoregulation (exposure to cold stress increases oxygen and glucose needs)
- maintain body temp
- Eye prophylaxis - ophthalmia neonatorium (inflammation f eyes from gonorrheal or chlamydial infection contracted during passage through birth canal
- vit K - IM to prevent hemorrhagic disease of newborn (HDN)
Newborn Lab and Diagnostic Tests: Routine Testing
- hemoglobin and hematocrit
- blood glucose
- leukocytes
- bilirubin levels
- blood gases, arterial/venous
- newborn screening tests
- drug serum levels
Lab and Diagnostic Tests: Collection of specimens
- heel stick
- venipuncture
- obtaining a urine specimen (not standard)
Intramuscular Injection
- acceptable intramuscular injection site for newborn infant
- infants leg being stabilized for IM injection. The nurse is wearing gloves to give the injection
Umbilical Cord Care
Clamp is left on until the stump falls off
- usually around a week
- clean with soap and water and pat dry
Pain assessment in Term Newborn
Assessment include with VS assessments for healthy full-term newborns
- the newborn is unable to verbalize needs, the nurse should be alert for signs of pain
Assessment: VS before, during, and after invasive procedures
- observational and based on behaviours
- nursing skill and judgement to differentiate pain from other issues
- Nurses need skills to intervene appropriately
- Expected outcomes
1. infant is free from signs of pain
2. Parents express satisfaction with infant’s comfort level
Monitor for:
- facial expression: frowns, grimaces, and flinching
- increased HR, Resps, and BP associated with other signs
- high-pitched, tense, harsh crying
- increased movement of extremities and clenching of the fists
Non-pharmacological pain management
- further assessment, interventions prn
- removing cause of the pain (if signs continue, then further nursing assessment and intervention)
- lower the lights if possible and keep area quiet
- lay the infant supine with extremities flexed into the midline of the body
- contain the infant by skin-to-skin contact, holding, use of position devices, or cuddling
- Provide BF or non-nutritive sucking (pacifier) for comfort
AGA
appropriate for gestational age
Barlow’s Test
assess of newborn hips to detect for Hip Dysplasia. Hip is flexed and thigh is abducted as it is pushed posteriorly to the line of the femur’s shaft
Extrusion Reflex
outward protrusion of the newborn’s tongue when touched
