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APGAR
(Appearance, Pulse, Grimace, Activity, Respiration)

The APGAR test is done by a doctor, midwife, or nurse. The health care provider
will examine the babys:
Breathing effort
Heart rate
Muscle tone
Reflexes
Skins color

Each category is scored with 0, 1, or depending on the observed condition.

Breathing effort:
o If the infant is not breathing, the respiratory score (0).
o If the respirations are slow or irregular, the infant score (1) for
respiratory effort.
o If the infant cries well, the respiratory score is 2.

Heart rate is evaluated by stethoscope. This is most important assessment:
o If there is no heartbeat, the infant scores (0) for heart rate.
o If heart rate is less than 100 beats per minutes, the infants scores (2) for
heart rate.

Muscle tone:
o If muscles are loose and floppy , the infants scores (0) for muscle tone.
o If there is some muscle tone, the infants scores (1).
o if there is active motion, the infant scores (2) for muscle tone.

Grimace response or reflex irritability is a term describing response to
stimulation such as a mild pinch:
o If there is no reaction, the infant scores (0) for color.
o If there is no reaction, the infants scores (0) for reflex irritability,
o If there is grimacing. And a cough, sneeze, or vigorous cry, the infant
scores 2 for reflex irritability.
Skin color:
o If the skins color is pale blue, the infant scores (0) for color.
o If the body is pink and the extremities are blue, the infant scores (1) for
color.
o If the entire body is pink, the infant scores (2) for color.

Normal Results

The APGAR rating is based on a total score of (1) until (10). The higher the
score, the s better the cores, the baby is doing after birth.














VITAL SIGNS

Introduction

Vital sign monitoring is the intermittent assessment of temperature, pulse
respiration and blood pressure. Vita signs are often considered to be the baseline
indicators of a patients health status. Vital signs should be taken manually, not
copied from the monitor display. Exceptions to this are the oxygen saturation
reading and automatic (BP) readings from the monitor. The automatic BP
reading must be validate of a d with a manual BP at the beginning of a shift and /
or when a different electronic BP device is being used or when pressure readings
prompt concern. Interpret pressure readings with caution when an electric BP
device is used for an active infant: a Doppler may be a better choice. Automated
blood pressure readings should be performed at the time of documentation: any
readings that prompt concern should be repeated manually. External factors
including many disease conditions anxiety, pain exercise, and even circadian and
diurnal rhythms.

Heart Rate
Should be taken for one full minute
Infants and young children should have their heart rate taken at the apex of
the heart using a stethoscope
Patients who are older with no cardiac condition may have a radial pulse
take
Respiration
Should be taken for one minute
Auscultation on some patients (e.g.small ifants)
Respiratory rhythm and depth are also clinically important, and can be
determined with manually assessment and observation of the patients
respiratory pattern

Blood Pressure
Can be measured using a manual sphygmomanometer and stethoscope, by the
palpation of pulse technique, wit a Doppler or by using an electric BP device.


Vital Sings Ranges


Heart Rate
(beats/min)
Respiratory Rte
(respiratory/min)
Blood Pressure
0-1 month 93-182 26-65 45-80/33-52
1-3 months 120-178 28-55 65-85/35-55
3-6 moths 107-197 22-52 70-90/35-65
6-12 moths 108-178 22-50 80-100/40-65
1-2 years 90-152 20-50 80-100/40-70
2-3 years 90-158 20-40 80-100/40-80
3-5 years 74-138 20-30 80-110/40-80
5-7 years 65-138 20-26 80-115/40-80
8-10 years 62-130 20-26 85-125/45-85
11-13 years 62-130 14-22 95-135/45-85
14-18 years 62-120 12-22 100-145/50-90

Oral Rectal & Axillary Temperatures

Assessment of appropriate of temperature measurement:
Oral
Patients assessed as being developmentally and cognitively appropriate, an
who are not receiving oxygen via mask or hood
Patients who have not had surgery and/or do not have an inflammatory
condition of the mouth
Patients who do not have respiratory difficulties
Rectal
Patients who are beyond neonatal period
Patients who are unconscious or present difficulty with oral temperature
measurement related to cognitive function
Patients who have not had rectal surgery or other rectal abnormalities
Patient who are not immune compromised

Patients in the neonatal period (<28 days old)
Patients from whom oral and rectal temperatures are contraindicated

Temperature range Note:
There is no single definition of
fever
Fever should be interpreted
and managed in the context of
the patients age, illness and
clinical picture
Premature and small term
infants may no be able to
generate a










Method Range
(
O
C)
Fever
(
O
C)
Oral 36.5-37.5 38.0
Rectal 37.0-37.8 38.0
Axillary 36.1-37.1 37.3
THE CHARATERISTIC OF NORMAL NEWBORN

The characteristics of Normal Newborn : A newborn baby is said to normal if it
the following characteristics :

Normal newborn infants weighing 2.5 to 4 kg
Body length of 48-52 cm
Chest circumference 30-38 cm
Head circumference 33-35 cm
Newborns skins look red and slick with sub cutaneous tissue is quite
Lanugo hair is not visible, usually has a perfect head of hair
Rather long and weak nails
Genitalia : for women the labia majora and labia minora are covered for men
has dropped testicle scrotum existing
Suck and swallow reflex is well established
Morrow reflex when started or hugging motion is well
Graps or grasping reflex is good
Have good elimination, meconium newborn will come out withim the first
24 hours, with color brownish-black meconium










SCALE OF ANXIENTY

Based on scale HARS, calculate based on the level of anxiety, that is :
0 = no anxiety
1= mild anxiety
2= moderate anxiety
3= severe anxiety
4= very severe anxiety (panic)





















MUSCLE SCALE

0/1 : no contraction
1/5 : muscle flicker, but no movement
2/5 : movement possible, but no against gravity (test the joint in its
horizontal plane)
3/5 : movement possible against gravity, but not against resistance by the
examiner
4/5 : movement possible against some resistance by the examiner
(sometimes this category is subdivided further into 4
-
5, 4/5, and 4
+
/5)
5/5 : normal strength