Lecture notes

1. HIGH RISK NEWBORN
The high-risk neonate can be defined as a
newborn, regardless of gestational age or birth
weight, who has a greater-than-average
chance of morbidity or mortality because of
conditions or circumstances superimposed on
the normal course of events associated with
birth and the adjustment to extra uterine
existence.

2. CLINICAL ASSESSMENT OF
GESTATIONAL AGE
• A frequently used method of determining
gestational age is simplified assessment of
gestational age by Ballard, Novack and
Driver(1979) and it can be used to
measure gestational ages of infants
between 35 and 42 weeks. It assesses six
external physical and six neuro
muscular signs. Each sign has a number
score and the cumulative score correlates
with a maturity rating from 26 to 44 wks
of gestation.

3. Cont…
• The “new” Ballard scale, a revision of the
original scale, can be used with newborns
as young as 20 wks of gestation. The tool
has the same physical and neuro
muscular sections but includes -1 and -2
scores that reflect signs of extremely
premature infants.

4. Cont….
• The examination of infants with a
gestational age of 26 wks or less should
be performed at a postnatal age of less
than 12 hrs for infants with gestational
age of atleast 26 wks, the examination
can be performed upto 96 hrs after
birth.
• To ensure accuracy it is recommended
that the initial examination be
performed within the first 48 hrs of life.

5. SYSTEMATIC ASSESMENT
• A thorough systematic physical assessment is an
essential component in the care of the high-risk
infant. The alert nurse is aware of subtle changes
and reacts promptly to implement interventions
that promote optimum functioning in the high-risk
neonate.
• Observational assessments of the high-risk infant
are made according to the infant’s acuity; the
critically ill infant requires close observation
and assessment of respiratory function,
including continous pulse oximetry,
electrolytes and evaluation of blood gases.

6. Cont…
• Accurate documentation of the infant’s
status is an integral component of nursing
care. With the aid of continous,
sophisticated cardiopulmonary
monitoring, nursing assessment and
daily care may be coordinated to allow for
minimal handling of the infant to decrease
the effects of environmental stress.

7. PHYSICAL ASSESSMENT
GENERAL ASSESSMENT:
• Using electronic scale, weigh daily or more often
if ordered.
• Measure length and head circumference
periodically.
• Describe general body shape and size, posture
at rest, ease of breathing, presence and
location of edema.
• Describe any apparent deformities.
• Describe any signs of distress: poor color,
hypotonia, lethargy, apnea.

8. Respiratory assessment:
• Describe shape of chest (barrel, concave),
symmetry, presence of incisions, chest tubes
or other deviations.
• Describe use of accessory muscles: nasal
flaring or substernal, intercostal or
subclavicular retractions.
• Determine respiratory rate and regularity.
• Auscultate and describe breath sounds:
stridor, crackles, wheezing, wet or
diminished sounds, grunting, diminished air
entry, equality of breath sounds

9. Cont…
• Describe cry if not intubated.
• Describe ambient oxygen and method of
delivery if intubated. Describe size of tube,
type of ventilator and settings and method of
securing tube.
• Determine oxygen saturation by pulse oximetry
and partial pressure of oxygen and co2 by
transcutaneous oxygen and transcutaneous
co2.

10. CARDIOVASCULAR ASSESSMENT
:
– Determine heart rate & rhythm.
– Describe heart sounds, including any
murmurs.
– Determine the point of maximum intensity
(PMI). The point at which the heartbeat
sounds and palpates loudest (a change in the
PMI may indicate a mediastinal shift).
– Describe infant’s colour (may be of cardiac,
respiratory or hematopoietic origin);
cyanosis, pallor, plethora, juandice,
mottling.

11. Cont…
• Assess color of mucous membranes, lips.
• Determine blood pressure, indicate extremity
used and cuff size; check each extremity
atleast once.
• Describe peripheral pulses, capillary refill (<2
to 3 sec), peripheral perfusion (mottling).
• Describe monitors, their parameters and
whether alarms are in “on” position.

12. GASTROINTESTINAL ASSESSMENT
• Determine presence of abdominal distention:
increase in circumference, shiny skin,
evidence of abdominal wall erythema, visible
peristalsis, visible loops of bowel, status of
umbilicus.
• Determine any signs of regurgitaion and time
related to feeding; character and amount of
residual of gavage fed; of nasogastric tube is
in place, describe type of suction, drainage
(color, consistency, ph)
• Describe amount, color consistency and odour
of any emesis.

13. Cont…
• Palpate liver margin (1-3 cm below right
costal margin).
• Describe amount, color and consistency
of stools; check for occult blood or
reducing substances if ordered or
indicated by appearance of stool.
• Describe bowel sounds: presence or
absence (must be present if feeding)

14. GENITO URINARY ASSESSMENT
• Describe any abnormalities of genitalia
• Describe amount (as determined by
weight), color, ph, labstick and specific
gravity of urine (to screen for adequacy
of hydration).
• Check weight (the most accurate
measure for assessment of hydration).

15. NEUROLOGIC-MUSCULOSKELETAL
ASSESSMENT
• Describe infant’s movements; random,
purposeful, jittery, twitching,
spontaneous, elicited, level of activity
with stimulation, evaluate based on
gestational age.
• Describe infant’s position or attitude:
flexed , extended.
• Describe reflexes observed: moro,
sucking, babinski, plantar reflex, and
other expected reflexes.

16. Cont…
• Determine level of response and
consolability.
• Determine changes in head circumference
(if indicated): size and tension of
fontanels, suture lines.
• Determine pupillary responses in infant
>32 wks of gestation
• Check hip alignment (only experience
practitioner should perform).

17. TEMPERATURE
• Determine skin and axillary
temperature.
• Determine relationship to environmental
temperature .

18. SKIN ASSESSMENT
• Describe any discoloration, reddened
area, signs of irritation, blisters,
abrasions, especially where monitoring
equipment, infusions or other apparatus
come in contact with skin; also check and
note any skin preparation used (eg;
povodine iodine tape).
• Determine texture and turgor of skin; dry,
smooth, flaky, peeling etc.,

19. Cont…
• Describe any rash, skin lesion or birth marks.
• Determine whether IV infusion catheter or
needle is in place and observe for signs of
infiltration.
• Describe parenteral infusion lines; location,
type (arterial, venous, peripheral, umbilical,
central, peripheral central venous); type of
infusion (medication, saline, dextrose,
electrolyte, lipids, TPN); type of infusion pump
and rate of flow; type of catheter or needle and
appearance of insertion site.