Nursing Care for the Newborn (( The Assessment )) p By : Mohammad Abuadas RN, MSN

The Initial Assessment  APGAR  APGAR scoring: The most frequently used method to assess the newborn’s immediate adjustment to extrauterine life is the APGAR scoring system. The score is based on observation to heart rate, respiratory effort, muscle tone, reflex irritability, and color, items measured 0,1,2 grades. The APGAR scoring is taken 1 & 5 minutes after birth, and repeated after newborn’s condition stabilizes. It assesses the physical & neurological status.

APGAR SCORE Sign 012 Heart RateAbsentSlow, < 100> 100 Respiratory effort Absent Irregular, slow, weak cry Good, strong cry Muscle toneLimp, flaccid Some flexion of extremities Well flexed Reflex irritability No responseGrimace Cry, sneeze Skin colorBlue, pale extremities blue (acrocynosis) Completely pink

APGAR Score Interpretation ScoreIntervention 8 – 10 ( Eight to ten ) No intervention is required 4 – 7 ( Four to seven ) Gently stimulate Rub newborn’s back Administer O2 to the newborn. 0 – 3 ( Zero to three ) Infant requires resuscitation

Example A newborn assessed using APGAR scoring system, found with heart rate = 120 bpm, slow and weak cry, well flexed, the newborn found crying and sneezing as a response, and pale ….. how much in APGAR? And what will be your intervention ????.

Answer The signNewborn’s findings The score Heart rate120 bpm2 Respiratory effort Slow, weak cry1 Muscle toneWell flexed2 Reflex irritability Sneeze, cry2 Skin colorPale0 Total 7 ???!!!

Assessment for gestational age (Ballard scale) Posture :Posture : With infant quite and in supine position, observe degree of flexion in arms and legs. Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs = 4.

Square window:Square window: with thumb supporting back of the arm below wrist, apply gentle pressure with index and third fingers of dorsum of hand without rotating infant’s wrist. Measure angle between base of thumb and forearm=4

Arm recoilArm recoil: with infants supine, fully flex both forearms on upper arms, hold for 5 minutes; pull down on hands to fully extend and rapidly release arms. Observe rapidity and intensity to of recoil to a state of flexion. A brisk return to flexion = 4

Popliteal anglePopliteal angle : With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. While holding knee with thumb and the index finger, extend lower leg with index finger of other hand. Measure degree of angle behind knee. An angle of less than 90 degrees = 5.

Scarf sign:Scarf sign: With infant supine, support hand in midline with one hand; use other hand to pull infant’s arm across the shoulder so that infant’s hand touches shoulder. Determine location of elbow in relation to midline. Elbow doesn't reach midline = 4

Heal to ear sign:Heal to ear sign: With infant supine, and pelvis flat on a firm surface, pull foot as far as possible up toward ear on same side. Measure distance of foot from ear and degrees of knee flexion ( same popliteal angle). Knees flexed with a popliteal angle of less than 90 degree = 4

Weight related to gestational age Appropriate for gestational age 10 th -90 th. Small for gestational age < 10 th. Large for gestational age > 90 th. The normal birth weight is g.

Growth measures Head circumference : cm Chest circumference : cm, 2 cm less than head circumference. Abdominal circumference. Length: head (cephalic) to heal: cm Body weight : g. ( loses 10% of weight in the first 3 to 4 days after birth).

Vital signs Axillary temperature: Avoid rectal in the first day. Pulse : bpm Respiration : bpm Blood pressure : 65/41 mmHg in the first 3 days. Compared with lower extremities. Vital signs must be checked every hour for 2 hours, then once every 8 hours until discharge.