OCCUPATIONAL THERAPY TRAINING SCHOOL AND CENTRE SETH G.S. MEDICAL COLLEGE & KING EDWARD MEMORIAL HOSPITAL OCCUPATIONAL THERAPY NEONATAL EVALUATION DATE OF EVALUATION: Time of evaluation: Name: Date of Birth: History:
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Sex: Est. Gest. Age at Birth:
Corrected Age:
Precautions: _____________________________________________________________________ Complications: right/left IVH grade____ PVL ______ Shunt____ ROP_____ Other: _____________________________________________________________ Interventions: ETT ECMO Trach NCPAP NC RA OG/NG/GT Replogle Ostomy IV Isolette/ Table/ Basinette/ Crib Physiological baseline: HR______ O2_____RR_______ Change in Vital Signs: HR ↑ ↓ O2 ↑ ↓ RR ↑ ↓ Stable Physical presentation: ____________________________________________________________ ________________________________________________________________________________ Pain: yes/ no NPASS: Cry___State ___Face ___ Tone _____ VS ___Correction for age__ Total __ OBSERVATION State Control : □ Deep sleep□ Light sleep □ Drowsy □ Quiet alert □ Active awake □ Crying □ Self consoling □ Calms with external supports □ Purposeful movements Stress Signs: □ Changes in Vital signs □ Color changes □ Tongue thursts □ Yawning □ Finger Splay □ Saluting □ Sitting on air □ Gaze aversion □ Staring □ Hyperalertness □ Startling □ Tremors □ Abrupt transitions between states □ Arching □ Frantic Activity □ Hiccups □ Sneezing
Self – Regulatory Behaviors: Coping Signs Approach Signs □ Sucking □ Stable vital signs □ Hand to face □ Stable color □ Hand clasping □ Smooth respirations □ Foot clasping □ Hand mouth □ Leg bracing □ Grasping □ Trunk tucking □ Smiling □ Smooth movements □ Focusing □ Alertness □ Cooing □ Well modulated muscle tone □ Smooth transition between states
1 Trial Draft for OT Evaluation in NICU, Do Not Reproduce