Report- Initial Assessment

Overview:

This module aims to equip RTs with the knowledge and skills necessary for effective neonatal assessment in the NICU setting. It covers:

• Components of a thorough bedside handoff report

• Steps for initial patient assessment during the first shift

• Verification and understanding of medical orders

• Interpretation of arterial blood gases (ABGs)

• Evaluation of chest X-rays (CXRs)

• Development of a comprehensive respiratory care plan

A. Core Components of a NICU Bedside Respiratory Handoff

1. Patient Demographics & Clinical Context

• Name, DOB, MRN, Gestational Age (GA), Corrected Gestational Age (CGA), Birth Weight, and Current Weight.

• Chronologic Age and NICU day number (e.g., Day of Life 3, NICU Day 2).

• Mode of delivery, Apgar scores, resuscitation details (e.g., PPV, intubation), maternal history (e.g., chorioamnionitis, GBS status), and antenatal steroid exposure.

2. Primary Diagnosis and Medical History

• Examples: Respiratory Distress Syndrome (RDS), Meconium Aspiration Syndrome (MAS), Bronchopulmonary Dysplasia (BPD), Persistent Pulmonary Hypertension of the Newborn (PPHN), congenital anomalies, etc.

• Surgical history or procedures relevant to respiratory care (e.g., PDA ligation, CDH repair).

3. Respiratory Status

• Current mode of respiratory support: CPAP, NIPPV, HFNC, SIMV, AC/PC, HFOV, or ECMO.

• Ventilator settings: PIP, PEEP, RR, FiO₂, Vt (if applicable), i-Time, MAP (for HFOV), amplitude, frequency.

• Recent changes: Include why adjustments were made, response to changes.

• ETT size, position (lip-to-tip), and tape date, including any known air leaks or issues with fixation.

4. Gas Exchange and Blood Gases

• Most recent arterial, capillary, or venous blood gases (with time), and interpretation:

  • pH, PaCO₂, PaO₂, HCO₃⁻, Base Excess.

  • Whether this value is trending toward normalization or decompensation.

• Current SpO₂ target range per protocol (especially if the infant has BPD or PPHN).

5. Imaging and Procedures

• Date and findings of most recent chest X-ray: Lung inflation, atelectasis, infiltrates, ET tube placement, line placements.

• Any recent endotracheal suctioning, bronchoscopy, surfactant administration (date/time/dose).

6. Medications & Therapies

• Current medications: caffeine citrate, albuterol, diuretics, inhaled nitric oxide (iNO).

• Surfactant history (type, dose, response).

• Weaning protocols or ongoing titration plans.

7. Events of the Day

• Desaturation episodes, bradycardias, or any resuscitative events.

• Recent transport or procedure requiring respiratory support modification.

8. Plan and Anticipated Needs

• Ventilator wean plan, ABG timing, CXR follow-up, extubation readiness, trial off NCPAP, etc. The plan can be one of the most important aspects to consider since we are going to be working towards this goal.

• Anticipated interventions (e.g., repeat surfactant, trial of steroids for BPD).

9. Handoff Best Practices

• Use a structured format such as SBAR (Situation, Background, Assessment, Recommendation) or IPASS to organize information.

• Keep it concise but thorough—focus on respiratory-relevant data while being aware of broader clinical context.

• Verify understanding: Always ask and answer clarifying questions to confirm that both parties share the same mental model.

• Include parental presence or concerns, especially if they influence care decisions (e.g., parent declines certain interventions).

Clinical Pearls

• Always confirm ventilator circuit integrity and humidification at shift change.

• Validate that the ETT/tube position is secure and matches documentation.

• Consider skin integrity and pressure areas from respiratory devices during bedside check.

• Reassess whether ABG frequency is appropriate for the level of support.

• Never rely solely on prior shift notes—assess the infant yourself immediately after report.

B. Components of the Initial NICU Respiratory Assessment

1. Review of Medical Records and Orders

Before approaching the bedside, review:

• Admitting diagnosis and history (e.g., GA, RDS, MAS, BPD, congenital anomalies)

• Delivery room events (resuscitation, intubation attempts, APGARs, initial FiO₂)

• Respiratory orders:

  • Mode and parameters (e.g., SIMV, HFOV)

  • FiO₂ target range and alarm limits

  • ABG schedule

  • Medication orders (e.g., surfactant, iNO, caffeine)

• Ventilator weaning or escalation plans

• Lab & imaging orders, including most recent ABG and CXR

2. Physical and Clinical Assessment

Use a “look, listen, feel” approach, integrating objective findings with your clinical observations.

A. General Appearance

• Muscle tone, posture, spontaneous movement

• Color: Pink, pale, mottled, acrocyanosis, central cyanosis

B. Work of Breathing (WOB)

• Respiratory rate and pattern (normal: 30–60/min)

• Nasal flaring

• Grunting

• Retractions (suprasternal, intercostal, subcostal)

• Paradoxical breathing or seesaw motion

C. Auscultation

• Breath sounds: clear, diminished, crackles, wheezes, asymmetry Work of breathing Assessment is crucial

• Presence of transmitted upper airway sounds vs. true lower airway pathology

D. Cardiorespiratory Status

• Heart rate (normal: 100–160 bpm), murmur presence

• Oxygen saturation trends—baseline and variability

• Capillary refill, skin temperature, perfusion quality

E. Behavioral State

• Cry strength (weak cry may suggest fatigue or hypoventilation)

• Irritability or lethargy may reflect rising CO₂ or poor oxygenation

3. Equipment and Interface Check

A. Ventilator / Support Interface

• Confirm ventilator mode and settings match written orders

• Ensure:

  • No tubing kinks or leaks

  • Circuit secure at Y-connector

  • Bubble CPAP bubbling continuously (if applicable)

  • FiO₂ delivery accuracy (blender calibration, analyzers)

  • Heater/humidifier is functional and delivering appropriate temps

B. ETT or Cannula

• Verify ETT size, placement at the lip (per documentation), cuff pressure (if applicable)

• Inspect securement device or tape condition

• Confirm placement with bilateral breath sounds and CXR (if recent)

C. Monitors & Alarms

• Proper SpO₂ probe placement and signal

• HR, RR, SpO₂ alarm limits appropriate and functional

• Apnea monitors and backup respiratory rate set (for NIV)

4. Diagnostics Review

A. Arterial/Capillary Blood Gas

• Review most recent results:

  • pH, PaCO₂, PaO₂, HCO₃⁻, Base Excess

• Assess trends (improving, worsening, or stable)

• Correlate with clinical condition and ventilator settings

B. Chest X-Ray

• Review recent CXR for:

  • Lung volume (atelectasis vs. hyperinflation)

  • Tube/line position (ETT, UVC/UAC, OG/NG, PICC)

  • Pulmonary infiltrates, pneumothorax, or air leak syndromes

📝 Pro tip: Overlay your physical findings (e.g., decreased right breath sounds)

with radiographic data to confirm or challenge your initial impression.

5. Documentation and Clinical Planning

• Chart a detailed initial respiratory assessment, including:

  • WOB, auscultation, color, respiratory support, patient response

  • Any discrepancies between charted settings and observed equipment

• Communicate findings during rounds or huddles

• Adjust ventilator settings per protocols or communicate need for changes

• Identify and document goals for the shift:

  • Weaning, ABG timing, readiness for extubation, diagnostic follow-ups

Clinical Pearls

• Never ignore subtle behavior changes—they can precede desaturations or CO₂ retention.

• If the patient “doesn’t look right,” start from the beginning. Reassess everything.

• Trust trends, not isolated readings—but investigate all abnormalities.