Pediatric Assessment

PEDIATRIC ASSESSMENT Immediately after delivery, the general state of the newborn should be evaluated while the infant is supine under a radiant warmer with the temperature probe attached to the abdomen. APGAR scores are assigned at 1 and 5 minutes after delivery.

APGAR SCORE ASSESMENT PROCEDURE

NORMAL FINDINGS

Auscultate apical pulse

>100 bpm

Inspect chest and abdomen for respiratory effort. Stroke back or soles of feet.

Crying

Inspect muscle tone by extending legs and arms. Observe degree of flexion and resistance in extremities. Inspect muscle tone by extending legs and arms. Observe degree of flexion and resistance in extremities. Determine total apgar score at 1 and 5 minutes after birth

Extremities flexed, active movement

Crying

DEVIATIONS FROM NORMAL <100 bpm indicates bradycardia; absent heart beat indicates fetal distress. Absent, slow, irregular respirations. Delayed neurologic function may be seen in grimace, no response. Moderate degree of flexion, limp may indicate neurologic deficits.

Full body pink. Acrocyanosis

Cyanosis, pale

8-10 points

<8 points indicate poor transition from intrauterine into extrauterine life.

APGAR SCORING Heart rate Respiratory rate Reflex irritability

0 Absent Absent No response

Muscle tone

Flaccid, limp

1 <100 bpm Slow, irregular Grimace, some motion Flexion of

2 >100 bpm Good lusty cry Cry, cough Active flexion

Color

Cyanotic, pale

extremities Pink body, Acrocyanosis

Pink body, pink extremities

After the Apgar score has been assigned, a thorough assessment including vital signs, measurements, and gestational age assessment is performed. PROCEDURE

NORMAL FINDINGS

Monitor axillary temperature.

36.4—37.2

Inspect and Auscultate lung sounds.

Easy, nonlabored, clear lungs bilaterally

Monitor respiratory rate.

Rate: 30-60 breaths/min

Auscultate apical pulse.

Regular 120-160 bpm (100 sleeping, 180 crying)

Weigh newborn unclothed using a newborn scale. Measure length

2,500-4,000 g

Measure head circumference Measure chest circumference

33-35 cm

44-5 cm

30-33 cm

DEVIATIONS FROM NORMAL FINDINGS <36.4°: hypothermia, which may indicate sepsis >37.2: hyperthermia, which may indicate infection or improper monitoring of temperature probe Labored breathing, nasal flaring, ronchi, rales, retractions, grunting Rate <30 or >60 breaths/min is seen with respiratory distress Irregular <100 or >180 bpm may indicate cardiac abnormalities <2,500 g >4,000 G <44 cm >55 cm <33 cm >35 cm <29 cm >34 cm

ASSESSMENT OF GESTATIONAL AGE The newborn’s gestational age is examined within 4 hours after birth to identify any potential age-related problems that may occur within the next few hours. The newborn’s neuromuscular and physical maturity is examined. After examination, boxes on New Ballard Scale that most closely describe and depict the newborn’s neuromuscular and physical maturity are marked, and scores are assigned to assess gestational age. PROCEDURE

NORMAL FINDINGS

DEVIATIONS FROM NORMAL

Assess neuromuscular maturity • Posture 9with newborn undisturbed)

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Square window: bend wrist toward ventral forearm until resistance is met Arm recoil: bilaterally flex elbows up with hands next to shoulders and hold approximately 5 seconds; extend arms down next to side, release; observe elbow angle and recoil Popliteal angle: flex thigh on top of abdomen; push behind ankle and extend lower leg toward head until resistance is met; measure angle behind knee. Scarf sign: lift arm across chest toward opposite shoulder until resistance is met; note location of elbow in relation to middle of chest Heel to ear: pull leg toward ear on same side, keeping

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Arms and legs flexed

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0-30°

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Elbow angle <90°, rapid recoil to flexed state

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<100°

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Elbow position less than midline of chest

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Popliteal angle <90°, heel distal from ear

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Arms and legs limp, extended away from body seen with premature infants Premature infants may have square window measurement of >30°

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Elbow angle >110°, delayed recoil seen in premature infants

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>100°

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Elbow position midline of chest or greater, toward opposite shoulder seen in premature infants.

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Popliteal angle >90°, heel proximal to ear seen in premature infants

buttocks flat on bed, inspect popliteal angle and proximity of heel to ear.

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Few or no vessels in the abdomen, cracking in ankle area especially

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Thinning, balding on back, shoulders, knees

Assess physical maturity • Observe skin

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Inspect plantar surface of feet for creases

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Inspect and palpate breast bud tissue with middle finger and forefinger; measure bud in millimeters Observe ear cartilage in upper pinna for curving. Fold pinna down toward side of head and release, observe recoil of ear. Inspect genitals. Male: observe scrotum for rugae an palpate position of testes Female: observe labia majora, labia minora and clitoris

Creases on anterior two thirds or entire sole •

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Inspect for lanugo •

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Raised areola, full areola

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Pinna well curved, cartilage formed, instant recoil

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Male; deep rugae; testes positioned down in scrotal sac Female: Labia majora cover minora and clitoris

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Total score: 35-45

Translucent, visible veins, rash, leathery, wrinkled skin seen in postmature infants Abundant amount of fine hair on face seen in premature infants Anterior transverse crease on sole only, no creases, fewer creases indicate prematurity Absence of bud tissue, bud <3 mm seen in premature infants

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Pinna slightly curved, slow recoil seen in premature infants

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Male: Decreased presence of rugae; testes positioned in upper inguinal canal Female: labia majora and labia minora equally prominent seen with premature infants

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Total score: <35

points • Determine score rating • Add the total scores from both tables • Plot total score in column on righthand side of page; this score corresponds to the number in weeks on the maturity rating scale, circle the number of weeks. • Using gestational weeks assessed, plot weight, length and head circumference

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Gestational age: 3842 weeks

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10th through 90th percentile is appropriate for gestational age

points or >45 points Gestational age: <38 or >42 weeks

Les s than 10th percentile (small for gestational age), greater than 90th percentile (large for gestational age)