COMPLETE HEAD-TO-TOE SKIN ASSESSMENT
The more complete head-to-toe assessment begins with observation, listening and smell. Wear gloves if the infant has not had the first bath. Inspect the naked newborn in a well-lit, warm area. Check for skin color, rashes or birthmarks. Assess for hydration.
Skin Color
The skin color should be pink. Vernix Caseosa
may be present on the skin after birth and may remain in the skin folds after the first bath. Vernix is normal. Lanugo is most noticable on the shoulders, forehead and cheeks. Acrocyanosis in the first 24 to 48 hours is normal. Ruddy or dark red color may occur with prematurity or polycythemia. Palor occurs with cardiovascular problems, blood loss or infection. Cyanosis or blue or gray color of skin or lips (circumoral cyanosis) can occur with infection, hypothermia, hypoglycemia, respiratory or cardiac difficulties. Mottled skin can occur if the infant is cold. It will resolve as the infant is warmed. Jaundice or yellowing of the skin can occur in the first days. It is usually due to high bilirubin levels from hemolysis of red blood cells. A green skin color may be due to in utero release of meconium stool by the fetus before birth. Odor may indicate an intrauterine infection.
Review the flash cards to become familiar with variations of skin assessment.
SKIN ASSESSMENT TERMINOLOGY
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