DEGREE OF ACTIVITY (Reactivity to hygiene and comfort care and compatibility of the wake/sleep cycle with their need for food)
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1=Calm baby, alternating between vigil and sleep periods, waking up to feedings and hygiene and comfort care |
2=Sleepy baby in hygiene and comfort care, needs little encouragement to breastfeed |
3=Very sleepy baby, needs consistent and continuous nursing stimulation OR tearful baby |
4=Very angry baby OR tearful OR sedated OR non-reactive |
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CONTROL MEASUREMENT INTERVAL (Need for observation and control of data such as temperature, O2 saturation, heart or respiratory rate, capillary blood glucose)
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1=Control intervals greater than 5 hours |
2=Control intervals between 4 and 5 hours |
3=Control intervals between 2 and 3 hours |
4=Control intervals less than 2 hours |
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OXYGENATION (Possibility of the baby maintaining normal airway permeability, ventilation, and oxygenation)
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1=Spontaneous breathing, without the need for oxygen therapy or airway clearance |
2=Spontaneous breathing, requiring airway clearance by instillation of serum |
3=Spontaneous breathing, requiring airway clearance due to aspiration of secretions and/or need for oxygen therapy |
4=Ventilation (Non-Invasive or Invasive) |
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FOOD AND HYDRATION (Possibility of the baby receiving fluids and nutrients by ingestion or by enteral or parenteral infusion)
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1=Effective breastfeeding |
2=Via oral by cup or bottle |
3=Via catheters (gastric, post-pyloric or gastrostomy) or need breastfeeding or oral assistance, with increased risk of aspiration |
4=Special assistance in breastfeeding/Translactation and/or Parenteral nutrition |
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EXCRETION (Baby’s conditions for urinary and intestinal excretion)
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1=Excretion in diapers at intervals equal to or greater than 3 hours |
2=Excretion in diapers at intervals between 2 to 3 hours |
3=Excretion in diapers at intervals of less than 2 hours |
4=Excretion by Probes and/or stomata |
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HYGIENE CARE AND POSITIONING (Body hygiene care and baby positioning)
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1=hygiene care and positioning performed in a common crib with a baby at intervals equal to or greater than 3 hours |
2=hygiene care and positioning performed in a common crib that includes an immersion bath |
3=hygiene care and positioning performed in an incubator or heated crib with a stable baby in care |
4=hygiene care and positioning in minimal handling due to baby’s instability in care |
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DRUG THERAPY (Baby’s need to receive medication)
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1=No medication needed |
2=Topical, ocular and/or oral medications with a calm baby |
3=Parenteral, enteral, inhaled OR topical, ocular OR oral medication with agitated baby |
4=Continuous intravenous using an infusion pump |
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DRESSINGS or SKIN CARE (Dressings or care for protection, prevention, maintenance or restoration of cutaneous-mucous integrity)
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1=Intact skin throughout the body area |
2=Need for LOW complexity care, such as: skin hydration, treatment of simple dermatitis, renewal of peripheral venous catheter fixation |
3=Need for MEDIUM complexity care, such as dressings on wounds limited to the skin, drain inserts, tracheostomy OR gastrostomy |
4=Need for HIGH complexity care, such as care with a central venous catheter AND/OR disseminated dermatitis, debridement, complexes stoma or wounds with visualization of muscle fascia, bone tissue or eviscerations |
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PARTICIPATION AND GUIDANCE OF THE MOTHER/FAMILY IN THE CARE OF THE NEWBORN (Performance and understanding of the mother or family regarding the orientations received and/or the provision of care consistent with the baby’s needs)
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1=Mother/family member understands the orientations received, recognizes and manages to meet the baby’s care needs during the preparation for hospital discharge |
2=Mother/family member understands the guidelines received and demonstrates availability to participate in the baby’s care, under the guidance of nursing |
3=Mother/family member understands the orientations received, but demonstrates difficulties to participate in the baby’s care and needs constant nursing assistance |
4=Mother/family member demonstrates difficulties in understanding the orientations received and/or demonstrates unavailability to participate in the baby’s care |
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CLASSIFICATION SCALE IN CARE CATEGORIES*
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9 to 17 points: High dependence on care (NB stable from a clinical and nursing point of view) |
18 to 26 points: Semi-intensive care (NB subject to clinical instability without imminent risk of death) |
27 to 36 points: Intensive care (NB with imminent risk of death, needs permanent and specialized medical and nursing assistance) |
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*Care categories are obtained from the sum of the points assigned to each indicator |