APGAR Scoring in Newborns

Assessment of the High Risk Newborn: APGAR Scoring

• APGAR scoring is a numerical expression of the newborn's adaptation to extra uterine life at 1 and 5 minutes after birth.
• APGAR scoring involves 5 aspects: heart rate, respiratory effort, muscle tone, reflex irritability, and color.

Heart Rate

• Heart rate is determined by auscultating the newborn's heart.
• It is the best way to determine heart rate.

Respiratory Effort

• Newborns usually cry spontaneously at about 30 seconds after birth.
• Respiratory effort is observed in the presence of breath sounds.

Muscle Tone

• Mature newborns hold their extremities tightly flexed, simulating their intrauterine position.
• They should resist any effort to extend their extremities.
• Poor muscle tone is observed when the infant shows no flexion of the arms and legs, and the extremities "flop" back to the mattress when manipulated or flexed.

Reflex Irritability

• One of two possible cues is used to evaluate this point: response to a suction catheter in the nostrils (cough or sneeze) or response to having the soles of the feet slapped (cry and withdrawal of foot).

Color

• All infants appear cyanotic at the moment of birth.
• They grow pink with or shortly after the first breath.
• The color of the newborn corresponds to how well they are breathing.

Newborn Care

• Newborns need to be assessed at birth for obvious congenital anomalies and gestational age.
• Assessments should be made with an infant under a prewarmed radiant heat warmer to guard against heat loss.

Nursing Diagnosis

• Ineffective airway clearance is related to the presence of mucus or amniotic fluid in the airway.
• Ineffective cardiovascular tissue perfusion is related to breathing difficulty.
• Nursing care involves initiation and maintenance of respirations, establishment of extrauterine circulation, and maintenance of fluid and electrolyte balance, among others.

Continuing Assessment

• Continuing assessment of high-risk infants involves the use of instrumentation such as cardiac, apnea, and blood pressure monitoring.
• Close observation is crucial and cannot be replaced by monitor equipment.