Neonatal and Pediatric Respiratory Care Examination PDF PDF

Examination and Assessment of the Neonatal and Pediatric Patient CHAPTER 4 43 used as a predictive index of neonatal mortality and ne...

Examination and Assessment of the Neonatal and Pediatric Patient CHAPTER 4 43 used as a predictive index of neonatal mortality and neurologic or developmental outcome and continues to be used as the best-established index of immediate postnatal health.8 The Apgar score obtained 1 minute after delivery provides an immediate evaluation of the infant and an objective measure for evaluating future interventions. However, in the delivery room resusci- FIGURE 4-2 Meconium aspirator.  (From Pfenninger JL, Fowler GC: tation may be well underway at the 1-minute mark Pfenninger and Fowler’s procedures for primary care, ed 3, Philadelphia, and should not be interrupted for Apgar scoring. 2011, Saunders.) Scoring again at 5 minutes of age gives information about the infant’s ability to recover from the stress of birth and adapt to extrauterine life. When the 5-minute Infants who are not vigorous (i.e., no or poor respira- Apgar score is less than 7, additional scores are usually tory effort, heart rate less than 100 beats per minute, obtained at 5-minute intervals until the score is greater poor muscle tone) may receive direct laryngotracheal than 7. Survival of the infant is unlikely if the score suctioning.4 remains 0 after 10 minutes of resuscitation.9 For direct laryngotracheal suctioning, the infant The most important of the signs is heart rate, which should be intubated and suction applied directly to the indicates life or death. Failure of the heart rate to re- endotracheal tube with the help of a meconium aspira- spond to resuscitation is an ominous prognostic sign.8 tor (Figure 4-2). The practitioner should constantly Heart rate appears to be least affected by developmen- apply suction while removing the tube from the air- tal maturity but may still be inadequate because of way, repeating the intubation and suctioning proce- developmental difficulties in establishing cardiorespi- dure until meconium is no longer visible in the airway ratory function at birth. or until resuscitation is required. In the immediate newborn period, skin color has the weakest correlation with the other four compo- PROVIDING STIMULATION nents of the Apgar score. Also, color does not reliably If the newborn does not respond to the extrauterine correlate with umbilical arterial pH, carbon dioxide environment with a strong cry, good respiratory effort, pressure, and base excess.10 and the movement of all extremities, the infant requires stimulation. Flicking the bottoms of the feet, gently GESTATIONAL AGE AND SIZE ASSESSMENT rubbing the back, and drying with a towel are all ac- ceptable methods of stimulation. Slapping, shaking, Ideally, gestational age assessment is performed before spanking, and holding the newborn upside down are the neonate is 12 hours old, to allow the greatest reli- contraindicated and potentially dangerous to the in- ability for infants less than 26 weeks of gestational fant.6 In the delivery room the initial steps of warming, age.11-13 Evaluating gestational age requires consider- clearing the airway, and stimulation of the non– ation of several factors. The three main factors are as meconium-stained infant should occur within 30 sec- follows: onds after birth.4 Gestational duration based on the last menstrual cycle APGAR SCORE Prenatal ultrasound evaluation Introduced in 1952 by Virginia Apgar, the Apgar score Postnatal findings based on physical and neuro- (Table 4-1) is an evaluation of newborns based on five logic examinations factors: heart rate, respiratory effort, muscle tone, re- Postnatal examinations for determining gestational flex irritability, and skin color.7 Historically, propo- age include the Ballard score, which is based on exter- nents of the Apgar score have encouraged evaluation nal physical findings, and neurologic criteria. Often a of newborns immediately after birth. It has also been gray-white cheeselike substance, called vernix caseosa, Table 4-1 Apgar Scoring APGAR SCORE PARAMETER 0 1 2 Heart rate None ,100 beats/min.100 beats/min Respiratory rate None Weak, irregular Strong cry Skin color Pale blue Body pink, extremities blue Completely pink Reflex irritability (response to stimulation) No response Grimace Cry, cough, or sneeze Muscle tone Limp tone Some flexion Wmoell flexed 44 SECTION II Assessment and Monitoring of the Neonatal and Pediatric Patient Neuromuscular maturity –1 0 1 2 3 4 5 Posture Square window (wrist) >90° 90° 60° 45° 30° 0° Arm recoil 180° 140°–180° 110°–140° 90°–110°