Cyanosis
Cyanosis: Excerpt from Nursing: Interpreting Signs and Symptoms
Cyanosis—a bluish or bluish black discoloration of the skin and mucous membranes—results from excessive concentration of unoxygenated hemoglobin in the blood. This common sign may develop abruptly or gradually. It can be classified as central or peripheral, although the two types may coexist.
Central cyanosis reflects inadequate oxygenation of systemic arterial blood caused by right-to-left cardiac shunting, pulmonary disease, or hematologic disorders. It may occur anywhere on the skin and also on the mucous membranes of the mouth, lips, and conjunctiva.
Peripheral cyanosis reflects sluggish peripheral circulation caused by vasoconstriction, reduced cardiac output, or vascular occlusion. It may be widespread or may occur locally in one extremity; however, it doesn't affect mucous membranes. Typically, peripheral cyanosis appears on exposed areas, such as the fingers, nail beds, feet, nose, and ears.
Although cyanosis is an important sign of cardiovascular and pulmonary disorders, it isn't always an accurate gauge of oxygenation. Several factors contribute to its development: hemoglobin concentration and oxygen saturation, cardiac output, and partial pressure of arterial oxygen (Pao2). Cyanosis is usually undetectable until the oxygen saturation of hemoglobin falls below 80%. Severe cyanosis is quite obvious, whereas mild cyanosis is more difficult to detect, even in natural, bright light. In dark-skinned patients, cyanosis is most apparent in the mucous membranes and nail beds.
Transient, nonpathologic cyanosis may result from environmental factors. For example, peripheral cyanosis may result from cutaneous vasoconstriction following a brief exposure to cold air or water. Central cyanosis may result from reduced Pao2 at high altitudes.
Action stat!
If the patient displays sudden, localized cyanosis and other signs of arterial occlusion, place the affected limb in a dependent position and protect it from injury; however, don't massage the limb. If you see central cyanosis stemming from a pulmonary disorder or shock, perform a rapid evaluation. Take immediate steps to maintain an airway, assist breathing, and monitor circulation.
History and physical examination
If cyanosis accompanies less-acute conditions, perform a thorough examination. Begin with a history, focusing on cardiac, pulmonary, and hematologic disorders. Ask about previous surgery. Then begin the physical examination by taking the patient's vital signs and pulse oximetry. Inspect the skin and mucous membranes to determine the extent of cyanosis. Ask the patient when he first noticed the cyanosis. Does it subside and recur? Is it aggravated by cold, smoking, or stress? Is it alleviated by massage or rewarming? Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing.
Next, evaluate the patient's level of consciousness. Ask about headaches, dizziness, or blurred vision. Then test his motor strength. Ask about pain in the arms and legs (especially with walking) and about abnormal sensations, such as numbness, tingling, and coldness.
Ask about chest pain and its severity. Can the patient identify aggravating and alleviating factors? Palpate peripheral pulses, and test the capillary refill time. Also, note edema. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect any bruits.
Does the patient have a cough? Is it productive? If so, have the patient describe the sputum. Evaluate his respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Ask about sleep apnea. Does the patient sleep with his head propped up on pillows? Inspect the patient for asymmetrical chest expansion or barrel chest. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds.
Inspect the abdomen for ascites, and test for shifting dullness or fluid wave. Percuss and palpate for liver enlargement and tenderness. Also, ask about nausea, anorexia, and weight loss.
Medical causes
Arteriosclerotic occlusive disease (chronic).With arteriosclerotic occlusive disease, peripheral cyanosis occurs in the legs whenever they're in a dependent position. Associated signs and symptoms include intermittent claudication and burning pain at rest, paresthesia, pallor, muscle atrophy, weak leg pulses, and impotence. Late signs are leg ulcers and gangrene.
Blast lung injury.Cyanosis is a serious sign of blast lung injury. The impact of this condition on the lungs of affected individuals varies and may include tearing, contusion, edema, and hemorrhage. Other signs and symptoms may include chest pain, wheezing, hemoptysis, and dyspnea. Treatment for patients with blast lung injury typically involves high-flow oxygen, careful fluid management, possible intubation, and close observation in an intensive care setting.
Bronchiectasis.Bronchiectasis produces chronic central cyanosis. Its classic sign, however, is a chronic productive cough with copious, foul-smelling, mucopurulent sputum or hemoptysis. Auscultation reveals rhonchi and coarse crackles during inspiration. Other signs and symptoms include dyspnea, recurrent fever and chills, weight loss, malaise, clubbing, and signs of anemia.
Buerger's disease.With Buerger's disease, exposure to cold initially causes the feet to become cold, cyanotic, and numb; later, they redden, become hot, and tingle. Intermittent claudication of the instep is characteristic; it's aggravated by exercise and smoking and relieved by rest. Associated signs and symptoms include weak peripheral pulses and, in later stages, ulceration, muscle atrophy, and gangrene.
Chronic obstructive pulmonary disease (COPD).Chronic central cyanosis occurs in advanced stages of COPD and may be aggravated by exertion. Associated signs and symptoms include exertional dyspnea, a productive cough with thick sputum, anorexia, weight loss, pursed-lip breathing, tachypnea, and the use of accessory muscles. Examination reveals wheezing and hyperresonant lung fields. Barrel chest and clubbing are late signs. Tachycardia, diaphoresis, and flushing may also accompany COPD.
Deep vein thrombosis.With deep vein thrombosis, acute peripheral cyanosis occurs in the affected extremity associated with tenderness, painful movement, edema, warmth, and prominent superficial veins. Homans'sign can also be elicited.
Heart failure.Acute or chronic cyanosis may occur in patients with heart failure. Typically, it's a late sign and may be central, peripheral, or both. With left-sided heart failure, central cyanosis occurs with tachycardia, fatigue, dyspnea, cold intolerance, orthopnea, a cough, a ventricular or an atrial gallop, bibasilar crackles, and a diffuse apical impulse. With right-sided heart failure, peripheral cyanosis occurs with fatigue, peripheral edema, ascites, jugular vein distention, and hepatomegaly.
Lung cancer.Lung cancer causes chronic central cyanosis accompanied by a fever, weakness, weight loss, anorexia, dyspnea, chest pain, hemoptysis, and wheezing. Atelectasis causes mediastinal shift, decreased diaphragmatic excursion, asymmetrical chest expansion, a dull percussion note, and diminished breath sounds.
Peripheral arterial occlusion (acute).Peripheral arterial occlusion produces acute cyanosis of one arm or leg or, occasionally, both legs. The cyanosis is accompanied by sharp or aching pain that worsens when the patient moves. The affected extremity also exhibits paresthesia, weakness, and pale, cool skin. Examination reveals a decreased or an absent pulse and increased capillary refill.
Pneumonia.With pneumonia, acute central cyanosis is usually preceded by a fever, shaking chills, a cough with purulent sputum, crackles, rhonchi, and pleuritic chest pain that's exacerbated by deep inspiration. Associated signs and symptoms include tachycardia, dyspnea, tachypnea, diminished breath sounds, diaphoresis, myalgia, fatigue, a headache, and anorexia.
Pneumothorax.A cardinal sign of pneumothorax, acute central cyanosis is accompanied by sharp chest pain that's exacerbated by movement, deep breathing, and coughing; asymmetrical chest wall expansion; and shortness of breath. The patient may also exhibit rapid, shallow respirations; a weak, rapid pulse; pallor; jugular vein distention; anxiety; and the absence of breath sounds over the affected lobe.
Polycythemia vera.A ruddy complexion that can appear cyanotic is characteristic in polycythemia vera, which is a chronic myeloproliferative disorder. Other findings include hepatosplenomegaly, headache, dizziness, fatigue, aquagenic pruritus, blurred vision, chest pain, intermittent claudication, and coagulation defects.
Pulmonary edema.With pulmonary edema, acute central cyanosis occurs with dyspnea; orthopnea; frothy, blood-tinged sputum; tachycardia; tachypnea; dependent crackles; a ventricular gallop; cold, clammy skin; hypotension; a weak, thready pulse; and confusion.
Pulmonary embolism.Acute central cyanosis occurs when a large embolus causes significant obstruction of the pulmonary circulation. Syncope and jugular vein distention may also occur. Other common signs and symptoms include dyspnea, chest pain, tachycardia, a paradoxical pulse, a dry or productive cough with blood-tinged sputum, a low-grade fever, restlessness, anxiety, and diaphoresis.
Raynaud's disease.With Raynaud's disease, exposure to cold or stress causes the fingers or hands first to blanch and turn cold, then become cyanotic, and finally to redden with a return to a normal temperature. Numbness and tingling may also occur. Raynaud's phenomenon describes the same presentation when associated with other disorders, such as rheumatoid arthritis, scleroderma, or lupus erythematosus.
Shock.With shock, acute peripheral cyanosis develops in the hands and feet, which may also be cold, clammy, and pale. Other characteristic signs and symptoms include lethargy, confusion, an increased capillary refill time, and a rapid, weak pulse. Tachypnea, hyperpnea, and hypotension may also be present.
Sleep apnea.When chronic and severe, sleep apnea causes pulmonary hypertension and cor pulmonale (right-sided heart failure), which can produce chronic cyanosis.
Nursing considerations
▪ Provide supplemental oxygen to relieve shortness of breath, improve oxygenation, and decrease cyanosis.
▪ Deliver small doses of oxygen (2 L/minute) in the patient with COPD and in the patient with mild COPD exacerbations.
▪ For acute situations, a high-flow oxygen rate may be needed initially; in working with a patient who has COPD, remember to be attentive to his respiratory drive and adjust the amount of oxygen accordingly.
▪ Position the patient comfortably to ease breathing.
▪ Administer a diuretic, bronchodilator, antibiotic, or cardiac drug as needed.
▪ Make sure that the patient gets sufficient rest between activities to prevent dyspnea.
▪ Prepare the patient for such tests as arterial blood gas analysis, complete blood count, and imaging studies and scans to determine the cause of cyanosis.
Patient teaching
▪ Instruct the patient to seek immediate medical attention if cyanosis occurs.
▪ Discuss the safe use of oxygen at home.
▪ Explain to the patient his diagnosis and the treatment plan.
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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