POOR

APGAR

SCORING
 One minute — and again five minutes — after your
baby is born, doctors calculate his Apgar score to
see how he's doing. It's a simple process that helps
determine whether your newborn is ready to meet
the world without additional medical assistance.

This score — developed by anesthesiologist Virginia

Apgar in 1952 and now used in modern hospitals
worldwide — rates a baby's appearance, pulse,
responsiveness, muscle activity, and breathing with a
number between zero and 2 (2 being the strongest
rating). The numbers are totaled, and 10 is
considered a perfect score.
Purpose

Apgar scoring was originally developed in the 1950s by the

anesthesiologist Virginia Apgar to assist practitioners
attending a birth in deciding whether or not a newborn was
in need of resuscitation. Using a scoring method fosters
consistency and standardization among different
practitioners. A February 2001 study published in the New
England Journal of Medicine investigated whether Apgar
scoring continues to be relevant. Researchers concluded
that "The Apgar scoring system remains as relevant for
the prediction of neonatal survival today as it was almost
50 years ago".
 Description
The five areas are scored as follows:
Appearance, or color: 2 if the skin is pink all over; 1 for
acrocyanosis, where the trunk and head are pink, but
the arms and legs are blue; and 0 if the whole body is
blue. Newborns with naturally darker skin color will not
be pink. However, pallor is still noticeable, especially in
the soles and palms. Color is related to the neonate's
ability to oxygenate its body and extremities, and is
dependent on heart rate and respirations. A perfectly
healthy newborn will often receive a score of 9 because
of some blueness in the hands and feet.
Pulse (heart rate): 2 for a pulse of 100+ beats per
minute (bpm); 1 for a pulse below 100 bpm; 0 for no
pulse. Heart rate is assessed by listening with a
stethoscope to the newborn's heart and counting the
number of beats.
 Grimace, or reflex irritability: 2 if the neonate coughs,
sneezes, or vigorously cries in response to a stimulus (such
as the use of nasal suctioning, stroking the back to assess
for spinal abnormalities, or having the foot tapped); 1 for
a slight cry or grimace in response to the stimulus; 0 for
no response.
Activity, or muscle tone: 2 for vigorous movements of arms
and legs; 1 for some movement; 0 for no movement,
limpness.
Respirations: 2 for visible breathing and crying; 1 for slow,
weak, irregular breathing; 0 for apnea, or no breathing. A
crying newborn can adequately oxygenate its lungs.
Respirations are best assessed by watching the rise and
fall of the neonate's abdomen, as infants are
diaphragmatic breathers.
 Preparation
No preparation is needed to perform the test.
However, while being born the neonate may receive
nasal and oral suctioning to remove mucus and
amniotic fluid. This may be done when the head of
the newborn is safely out, while the mother rests
before she continues to push.
Aftercare
Since the test is primarily observational in nature,
no aftercare is needed. However, the test may
flag the need for immediate intervention or
prolonged observation.
 Normal results
The maximum possible score is 10, the minimum is zero. It is rare
to receive a true 10, as some acrocyanosis in the newborn is
considered normal, and therefore not a cause for concern. Most
infants score between 7 and 10. These infants are expected to
have an excellent outcome. A score of 4, 5, or 6 requires
immediate intervention, usually in the form of oxygen and
respiratory assistance, or perhaps just suctioning if breathing has
been obstructed by mucus. While suctioning is being done, a source
of oxygen may be placed near, but not over the newborn's nose and
mouth. This form of oxygen is referred to as blow-by. A score in
the 4-6 range indicates that the neonate is having some difficulty
adapting to extrauterine life. This may be due to medications given
to the mother during a difficult labor, or at the very end of labor,
when these medications have an exaggerated effect on the
neonate.
 Abnormal results
With a score of 0-3, the newborn is unresponsive,
apneic, pale, limp and may not have a pulse.
Interventions to resuscitate will begin immediately. The
test is repeated at five minutes after birth and both
scores are documented. Should the resuscitation effort
continue into the five-minute time period, interventions
will not stop in order to perform the test. The one-
minute score indicates the need for intervention at
birth. It addresses survival and prevention of birth-
related complications resulting from inadequate oxygen
supply. Poor oxygenation may be due to inadequate
neurological and/or chemical control of respiration. The
five-minute score appears to have a more predictive
value for morbidity and normal development, although
research studies on this are inconsistent in their
conclusions.
Apgar Sign 2 1 0
Apgar Scoring
Heart Rate Normal Below 100 Absent
(pulse) (above 100 beats per (no pulse)
beats per minute
minute)
Breathing Normal rate Slow or Absent (no
(rate and and effort, irregular breathing)
effort)
Grimace Pulls away, Facial Absent (no
(responsivene sneezes, or movement response to
ss or "reflex coughs with only (grimace) stimulation)
irritability") stimulation with
stimulation
Activity Active, Arms and No
(muscle spontaneous legs flexed movement,
tone) movement with little "floppy"
movement tone
Appearance Normal Normal Bluish-gray
(skin color all color (but or pale all
coloration) over (hands hands and over
and feet are feet are
pink) bluish)
 What is hypothermia?
The body maintains a relatively stable temperature whereby heat production is
balanced by heat loss. Normally, the core body temperature (when measured
rectally) is 98.6 degrees F or 37 degrees C. When the outside environment gets too
cold or the body's heat production decreases, hypothermia occurs (hypo=less +
thermia=temperature). Hypothermia is defined as having a core body
temperature less than 95 degrees F or 35 degrees C.
Body temperature is controlled in the part of the brain called the hypothalamus,
which is responsible for recognizing alterations in the body temperature and
responding appropriately. The body produces heat through the metabolic
processes in cells that support vital body functions. Most heat is lost at the skin
surface by convection, conduction, radiation, and evaporation. If the environment
gets colder, the body may need to generate more heat by shivering (increasing
muscle activity that promotes heat formation). But if heat loss is greater than the
body's ability to make more, then the body's core temperature will fall.
As the temperature falls, the body shunts blood away from the skin and exposure
to the elements. Blood flow is increased to the vital organs of the body including
the heart, lungs, kidney, and brain. The heart and brain are most sensitive to cold,
and the electrical activity in these organs slows in response to cold. If the body
temperature continues to decrease, organs begin to fail, and eventually death will
occur.
 What are the risk factors for hypothermia?
There are numerous factors that increase the risk of hypothermia:
Age: The very young and very old may be less able to generate heat.
The elderly with underlying medical conditions such as
hypothyroidism or Parkinson's disease that limit the ability of the
body to regulate temperature are less able to generate heat. Infants
don't generate heat as efficiently, and with their relatively large head
size compared to the body, they are at risk for increased heat loss by
radiation.

Mental status: Impaired judgment and mental function can lead to

cold exposure. Patients with Alzheimer's disease are prone to
wander and become exposed to the elements.

Substance abuse: Alcohol and drug abuse increase the risk of

hypothermia in two ways. First, impaired judgment can lead to cold
exposure. Additionally, alcohol and similar drugs can dilate blood
vessels near the skin (vasodilation) and decrease the efficiency of the
shivering mechanism, both of which decrease the body's ability to
compensate for cold exposure.
Medical conditions: Underlying medical conditions can also lead to accidental
hypothermia.

Patients with hormonal abnormalities (thyroid, adrenal, pituitary), and those

with peripheral neuropathy (due to diabetes or other conditions) or may be
less able to feel the cold and generate a shivering response.

Patients with spinal cord injuries, similarly, may not be able to adequately
shiver.

Patients who have suffered strokes or brain tumors may have impaired
thermal regulation centers in the brain.

Overwhelming infection and sepsis may both present with a lowered

temperature instead of fever. People with diabetes who have very low blood
sugar can appear unconscious and very cold.
Medications: Some medications can increase the risk of hypothermia by
 Hypothermia Symptoms by Body
Temperature
Celsius Fahrenheit Description Symptom
s
37 98.6 No No
hypothermia hypother
mia
Below 35 95 Definition of N/A
hypothermia
32 to 35 89.6 to 95 Mild Shivering
hypothermia Lethargy,
apathy,
confusion
28 to 32 82.4 to 89.6 Moderate Shivering stops
Increased
hypothermia confusion or
delirium
Slowing heart
rate; may be come
irregular

Below 28 Below 82.4 Severe Coma

hypothermia Ventricular
fibrillation
May appear
deceased

20 68 Brain
activity
stops
HYPOTHERMIA
 Hypothermia and its Management in Newborn
Introduction:
The normal newborn continues to adapt to the extra uterine life
within the first week after child birth remaining vulnerable to
hypothermia. The baby remains dependent on mother for nutrition
and protection.

Mother is responsible for maintaining the body temperature of the

baby among other functions essential for survival. Due to certain
characteristics such little subcutaneous fat, low birth weight babies,
exposing the baby to the cold climatic conditions increases risk of
hypothermia.
 Distribution and incidence

Hypothermia in the newborn occurs throughout the world, often

during the cooler seasons, and in regions where there is a large
temperature difference between day and night. As similar
environmental condition prevails in northeastern regions of India
the newborn are at risk of hypothermia.

In a study conducted in Ethiopia, on admission, 67% of low birth

weight and high-risk infants admitted to a special care unit were
hypothermic. In Nepal, during the winter months, over 80% of the
infants born became hypothermic after birth and 50% remained
hypothermic at 24 hours.

Many more research evidences are available supporting the role of

environmental temperature in the development of hypothermia in
newborn.
 Hypothermia in newborn

The newborn with a temperature of 36.0-

36.4°C (96.8-97.5°F) is under cold stress
(mild hypothermia). A baby with a
temperature of 32.0-35.9°C (89.6-96.6°F)
has moderate hypothermia, while a
temperature below 32°C (89.6°F) is
considered to be severe hypothermia..
 Signs of hypothermia

An early sign of hypothermia is feet that are cold to the touch. If

prolonged leads to hypothermia, the baby becomes less active,
suckles poorly, impaired feeding and has a weak cry.

In severely hypothermic babies the face and extremities may develop

a bright red colour. The baby becomes lethargic and develops slow,
shallow and irregular breathing and a slow heart beat.

Low blood sugar and metabolic acidosis, generalized internal

bleeding (especially in the lungs) and respiratory distress may occur.
Such a level of hypothermia is very dangerous and unless urgent
measures are taken, the baby will die.
 Effects of Hypothermia

There is no evidence that hypothermia has any beneficial effect

immediately after birth, for example cold stress is not needed at
birth, as commonly believed, to initiate or stimulate breathing.
Although many traditional practices are beneficial such as heating
the delivery room in cold weather, wrapping the baby and keeping it
close to the mother.

On the contrary there is sample evidence that hypothermia is

harmful. Prolonged hypothermia is linked to impaired growth and
may make the newborn more vulnerable to infections, others are
harmful such as sprinkling the newborn with cold water to stimulate
breathing, bathing the baby soon after birth, delaying breast-feeding
in the belief that colostrums is harmful or useless.
 Management of hypothermia
Thermal protection of the newborn is the series of measures
taken at birth and during the first days of life to ensure that
the baby does not become either too cold (hypothermia) and
maintains a normal body temperature of 36.5-37.5°C (97.7-
99.5°F).
Newborns found to be hypothermic must be rewarmed as
soon as possible. It is very important to continue feeding the
baby to provide calories and fluid. Breast-feeding should
resume as soon as possible.
If the infant is too weak to breast-feed, breast milk can be
given by, spoon or cup. It is important to be aware that
hypothermia can be a sign of infection. Every hypothermic
newborn should therefore be assessed for infection.
 Management in Hospital

In hospital a diagnosis of hypothermia is confirmed by measuring the

actual body temperature with thermometer.

In cases of mild hypothermia the baby can be rewarmed by skin-to-

skin contact, in a warm room (at least 25°C/77°F).

In cases of moderate hypothermia the clothed baby may be rewarmed

by the following measures:
 under a radiant heater;
 in an incubator, at 35-36°C (95-96.8°F);
 by using a heated water-filled mattress;
 in a warm room: the temperature of the room should be 32-34°C/89.6-
93.2°F
 in a warm cot: if it is heated with a hot water bottle, these should be
removed before the baby is put in.
 The rewarming process should be continued until the baby's
temperature reaches the normal range
 In cases of severe hypothermia studies suggest that fast rewarming
over a few hours is preferable to slow rewarming over several days.
Rapid rewarming can be achieved by using a thermostatically-
controlled heated mattress set at 37-38°C (98.6-100.4°F) or an air-
heated incubator.

The "warm chain" is a set of ten interlinked procedures carried out at

birth and during the following hours and days which will minimize
the likelihood of hypothermia.
 The room where the birth occurs must be warm (at least 25°C/77°F)
and free from draughts.
 At birth, the newborn should be immediately dried and covered,
before the cord is cut.
 While it is being dried, it should be on a warm surface such as the
mother's chest or abdomen (skin-to-skin contact).
 If this is not possible, alternative means of preventing heat loss and
providing warmth — such as wrapping, placing the baby in a warm
room or under a radiant heater.
 Bathing and weighing the baby should be postponed.
  Management at home
 At home, skin-to-skin contact is the best method to rewarm a baby.
 The room should be warm; the baby should be covered with a warm
blanket and be wearing a cap.
 The mother should continue breast-feeding as normal.
 If the baby becomes lethargic and refuses to suckle, these are danger
signs and it should be taken to hospital
 While being transported, the baby should be in skin-to-skin contact
with the mother during transportation.
 PREVENTION OF HYPOTHERMIA
 Refrain from bathing the newborn immediately post delivery.
 When bathing a neonate wash and dry only a small area of the body at
a time, keeping the rest of the infant's body covered.
 The baby should be dried well and then wrapped.
 Avoid unnecessary exposure when attending to baby's needs.
 The mother should keep the baby close to her body to avoid
hypothermia.
 In general, newborns need a much warmer environment than an adult.

Impaired Gas Exchange
NANDA Definition:
Excess or deficit in
oxygenation and/or carbon
dioxide elimination at the
alveolar-capillary
membrane.
• By the process of diffusion the exchange of oxygen and
carbon dioxide occurs in the alveolar-capillary
membrane area. The relationship between ventilation
(airflow) and perfusion (blood flow) affects the efficiency
of the gas exchange. Normally there is a balance between
ventilation and perfusion; however, certain conditions
can offset this balance, resulting in impaired gas
exchange. Altered blood flow from a pulmonary
embolus, or decreased cardiac output or shock can cause
ventilation without perfusion. Conditions that cause
changes or collapse of the alveoli (e.g., atelectasis,
pneumonia, pulmonary edema, and adult respiratory
distress syndrome [ARDS]) impair ventilation.
Other factors affecting gas exchange include high
altitudes, hypoventilation, and altered oxygen-carrying
capacity of the blood from reduced hemoglobin. Elderly
patients have a decrease in pulmonary blood flow and
diffusion as well as reduced ventilation in the dependent
regions of the lung where perfusion is greatest. Chronic
conditions such as chronic obstructive pulmonary
disease (COPD) put these patients at greater risk for
hypoxia. Other patients at risk for impaired gas
exchange include those with a history of smoking or
pulmonary problems, obesity, prolonged periods of
immobility, and chest or upper abdominal incisions.
Defining Characteristics:
•Restlessness
•Irritability
•Hypercapnia
•Hypoxia

Related Factors:
•Altered oxygen supply
•Alveolar-capillary membrane changes
•Altered blood flow
•Altered oxygen-carrying capacity of blood

Expected Outcomes :
Patient maintains optimal gas exchange as evidenced by
normal arterial blood gases (ABGs) and alert responsive
mentation or no further reduction in mental status.
 Ongoing Assessment
•Assess respirations: note quality, rate, pattern, depth, and breathing effort.
Both rapid, shallow breathing patterns and hypoventilation affect gas exchange.
Shallow, "sighless" breathing patterns postsurgery (as a result of effect of
anesthesia, pain, and immobility) reduce lung volume and decrease ventilation.
•Assess lung sounds, noting areas of decreased ventilation and the presence of
adventitious sounds.
•Assess for signs and symptoms of hypoxemia: tachycardia, restlessness,
diaphoresis, headache, lethargy, and confusion.
•Assess for signs and symptoms of atelectasis: diminished chest excursion,
limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal
shift to affected side. Collapse of alveoli increases physiological shunting.
•Assess for signs or symptoms of pulmonary infarction: cough, hemoptysis,
pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural
friction rub, fever.
•Monitor vital signs. With initial hypoxia and hypercapnia, blood pressure (BP),
heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes
more severe, BP may drop, heart rate tends to continue to be rapid with
arrhythmias, and respiratory failure may ensue with the patient unable to maintain
the rapid respiratory rate.
>Assess for changes in orientation and behavior. Restlessness is an early sign of
hypoxia. Chronic hypoxemia may result in cognitive changes such as memory
changes.
>Monitor ABGs and note changes. Increasing PaCO2 and decreasing PaO2 are
signs of respiratory failure. As the patient begins to fail, the respiratory rate will
decrease and PaCO2 will begin to rise. Some patients, such as those with COPD,
have a significant decrease in pulmonary reserves, and any physiological stress may
result in acute respiratory failure.
>Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry
is a useful tool to detect changes in oxygenation. Oxygen saturation should be
maintained at 90% or greater. This tool can be especially helpful in the outpatient or
rehabilitation setting where patients at risk for desaturation from chronic pulmonary
diseases can monitor the effects of exercise or activity on their oxygen saturation
levels. Home oxygen therapy can then be prescribed as indicated. Patients should be
assessed for the need for oxygen both at rest and with activity. A higher liter flow of
oxygen is generally required for activity versus rest (e.g., 2 L at rest, and 4 L with
activity). Medicare guidelines for reimbursement for home oxygen require a PaCO 2
less than 58 and/or oxygen saturation of 88% or less on room air. Oxygen delivery is
then titrated to maintain an oxygen saturation of 90% or greater.
>Assess skin color for development of cyanosis. For cyanosis to be present, 5 g of
hemoglobin must desaturate.
>Monitor chest x-ray reports. Chest x-rays may guide the etiological factors of the
impaired gas exchange. Keep in mind that radiographic studies of lung water lag
behind clinical presentation by 24 hours.

>Monitor effects of position changes on oxygenation (SaO2, ABGs, SVO2, and end-
tidal CO2). Putting the most congested lung areas in the dependent position (where
perfusion is greatest) potentiates ventilation and perfusion imbalances.

> Assess patient’s ability to cough effectively to clear secretions. Note quantity,
color, and consistency of sputum. Retained secretions impair gas exchange.
Therapeutic Intervention
>Maintain oxygen administration device as ordered, attempting to
maintain oxygen saturation at 90% or greater. This provides for adequate
oxygenation.
>Avoid high concentration of oxygen in patients with COPD. Hypoxia
stimulates the drive to breathe in the chronic CO2 retainer patient. When
applying oxygen, close monitoring is imperative to prevent unsafe increases
in the patient’s PaO2, which could result in apnea.

NOTE: If the patient is allowed to eat, oxygen still must be given to the
patient but in a different manner (e.g., changing from mask to a nasal
cannula). Eating is an activity and more oxygen will be consumed than
when the patient is at rest. Immediately after the meal, the original oxygen
delivery system should be returned.
>For patients who should be ambulatory, provide extension tubing or
portable oxygen apparatus. These promote activity and facilitate more
effective ventilation.
>Position with proper body alignment for optimal respiratory excursion
(if tolerated, head of bed at 45 degrees). This promotes lung expansion and
improves air exchange.
>Routinely check the patient’s position so that he or she does not slide
down in bed. This would cause the abdomen to compress the diaphragm,
which would cause respiratory embarrassment.
>Position patient to facilitate ventilation/perfusion matching. Use upright,
high-Fowler’s position whenever possible. High-Fowler’s position allows
for optimal diaphragm excursion. When patient is positioned on side, the
good side should be down (e.g., lung with pulmonary embolus or atelectasis
should be up).
>Pace activities and schedule rest periods to prevent fatigue. Even simple
activities such as bathing during bed rest can cause fatigue and increase
oxygen consumption.
>Change patient’s position every 2 hours. This facilitates secretion
movement and drainage.
>Suction as needed. Suction clears secretions if the patient is unable to
effectively clear the airway.
>Encourage deep breathing, using incentive spirometer as indicated. This
reduces alveolar collapse.
>For postoperative patients, assist with splinting the chest. Splinting
optimizes deep breathing and coughing efforts.
>Encourage or assist with ambulation as indicated. This promotes lung
expansion, facilitates secretion clearance, and stimulates deep breathing.

>Provide reassurance and allay anxiety: Have an agreed-on method for

the patient to call for assistance (e.g., call light, bell).
Stay with the patient during episodes of respiratory distress.

>Anticipate need for intubation and mechanical ventilation if patient is

unable to maintain adequate gas exchange. Early intubation and
mechanical ventilation are recommended to prevent full decompensation of
the patient. Mechanical ventilation provides supportive care to maintain
adequate oxygenation and ventilation to the patient. Treatment also needs to
focus on the underlying causal factor leading to respiratory failure.

>Administer medications as prescribed. The type depends on the

etiological factors of the problem (e.g., antibiotics for pneumonia,
bronchodilators for COPD, anticoagulants/thrombolytics for pulmonary
embolus, analgesics for thoracic pain).
Education/Continuity of Care
>Explain the need to restrict and pace activities to decrease
oxygen consumption during the acute episode.
>Explain the type of oxygen therapy being used and why its
maintenance is important. Issues related to home oxygen use,
storage, or precautions need to be addressed.
>Teach the patient appropriate deep breathing and coughing
techniques. These facilitate adequate air exchange and
secretion clearance.
>Assist patient in obtaining home nebulizer, as appropriate,
and instruct in its use in collaboration with respiratory
therapist.
>Refer to home health services for nursing care or oxygen
management as appropriate.
 NCM102

Presented by:
MERCADO JERA MACEE B.
BSN-II

Presented to:
Mr.MIKE DUMO
HAPPY NEW YEAR TO
ALL!!!
END ___