Clinical Practice Procedures: Assessment/APGAR score scor… · Clinical Practice Procedures:...
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Clinical Practice Procedures: Assessment/APGAR score
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Date February, 2015
Purpose To ensure a consistent procedural approach to determining the APGAR score.
Scope Applies to all QAS clinical staff.Author Clinical Quality & Patient Safety Unit, QAS
Review date February, 2017
URL https://ambulance.qld.gov.au/clinical.html
387QUEENSLAND AMBULANCE SERVICE
APGAR score
The APGAR score is a valuable method to determine the health
of newborns immediately after birth. It is determined by
allocating scores to five (5) simple criteria:
• colour ( A ppearance )• heart rate ( P ulse )• reflex irritability ( G rimace ) • muscle tone ( A ctivity ) • breathing ( R espiration )
Indications
Contraindications
• Nil in this setting
Complications
• All newly borns at one minute and five minutes following delivery.
• Nil in this setting
The purpose of the APGAR score is to
determine whether a newly born needs
immediate medical care. It is NOT designed to make long-term predictions of a child’s health.
[1,2]
February, 2015
Figure 3.18
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Procedure – APGAR score
• Using the table provided, assign the newborn a score (0 – 2) for each of the five criteria at 1 minute and agin at 5 minutes following delivery. Add all individual scores to calculate the total APGAR score (0 – 10). Additional information
An APGAR score of:
• 0 – 3 represents severe distress, (refer to CPG: Resuscitation – Newly born).
• 4 – 7 indicates moderate distress, (refer to CPG: Resuscitation – Newly born).
• 7 – 10 indicates an absence of difficulty
in adjusting to extrauterine life.
APGAR SCOREAPGAR SCOREAPGAR SCOREAPGAR SCOREAPGAR SCORE
Action 0 1 2
Appearance Look at skin colour
Blue/pale Pink
(extremities blue)All pink
Pulse Count heart rate
Absent < 100 > 100
Grimace Monitor response
No response
Grimace Vigorous
cough
Activity Look at muscle tone
Limp Some
flexion/extension Active
motion
Respiration Count and assess
Absent Slow/irregular Good cry
e
388QUEENSLAND AMBULANCE SERVICE
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