Cyanosis

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 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 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.

Emergency Actions

If the patient displays sudden, localized cyanosis and other signs of arterial occlusion, protect the affected limb 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

Begin with a history, focusing on cardiac, pulmonary, and hematologic disorders. Ask about previous surgery. While taking the patient’s history, evaluate his mental status and level of consciousness. 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. Ask about headaches, dizziness, or blurred vision. Ask the patient 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 any aggravating and alleviating factors? Also, ask about nausea, anorexia, and weight loss. Does the patient have a cough? Is it productive? If so, have the patient describe the sputum. Ask about sleep apnea. Does the patient sleep with his head propped up on pillows?

CULTURAL CUE:The lips of some black people have a bluish hue making it difficult to assess cyanosis. Establishing a baseline color of the patient’s skin and mucous membranes will help you detect color changes.

Physical assessment

Begin the physical assessment by taking vital signs. Evaluate respiratory rate and rhythm. Check for nasal flaring and use of accessory muscles. Inspect the skin and mucous membranes to determine the extent of cyanosis. Check the skin for coolness, pallor, redness, pain, and ulceration. Also note clubbing. Inspect the patient for asymmetrical chest expansion or barrel chest. Inspect the abdomen for ascites and test for shifting dullness or fluid wave. Palpate peripheral pulses, and test capillary refill time. Also, note edema.

Test the patient’s motor strength. Percuss the lungs for dullness or hyperresonance, and auscultate for decreased or adventitious breath sounds. Percuss and palpate for liver enlargement and tenderness. Auscultate heart rate and rhythm, especially noting gallops and murmurs. Also auscultate the abdominal aorta and femoral arteries to detect bruits.

Medical causes

Arteriosclerotic occlusive disease (chronic)

With chronic 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.

Bronchiectasis

Bronchiectasis produces chronic central cyanosis. Its classic sign, though, is 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

Chronic central cyanosis occurs in advanced stages of chronic obstructive pulmonary disease (COPD) and may be aggravated by exertion. Associated signs and symptoms include exertional dyspnea, 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.

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, cough, ventricular or atrial gallop, bibasilar crackles, and diffuse apical impulse. With right-sided heart failure, peripheral cyanosis occurs with fatigue, peripheral edema, ascites, jugular vein distention, and hepatomegaly.

Peripheral arterial occlusion (acute)

Acute peripheral arterial occlusion produces acute cyanosis of one arm or leg or, occasionally, of 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 decreased or absent pulse and increased capillary refill time.

Pneumonia

With pneumonia, acute central cyanosis is usually preceded by fever, shaking chills, 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, 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; weak, rapid pulse; pallor; jugular vein distention; anxiety; and absence of breath sounds over the affected lobe.

Polycythemia vera

A ruddy complexion that can appear cyanotic is characteristic in this chronic myeloproliferative disorder. Other findings in polycythemia vera 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; ventricular gallop; cold, clammy skin; hypotension; 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, paradoxical pulse, dry cough or productive cough with blood-tinged sputum, low-grade fever, restlessness, 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 to become cyanotic, and finally to redden with return of 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, increased capillary refill time, and a rapid, weak pulse. Tachypnea, hyperpnea, and hypotension may also be present.

Special considerations

Provide supplemental oxygen to relieve shortness of breath, improve oxygenation, and decrease cyanosis. Deliver small doses (2 L/minute) in patients with COPD, who may retain carbon dioxide. Use a low-flow oxygen rate for mild COPD exacerbations. For acute situations, a high-flow oxygen rate may be needed initially. Remember to be attentive to the patient’s 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 and complete blood count to determine the cause of cyanosis.

Pediatric pointers

Many pulmonary disorders responsible for cyanosis in adults also cause cyanosis in children. In addition, central cyanosis may result from cystic fibrosis, asthma, airway obstruction by a foreign body, acute laryngotracheobronchitis, or epiglottiditis. It may also result from a congenital heart defect, such as transposition of the great vessels, that causes right-to-left intracardiac shunting.

In children, circumoral cyanosis may precede generalized cyanosis. Acrocyanosis (also called “glove and bootee” cyanosis) may occur in infants because of excessive crying or exposure to cold. Exercise and agitation enhance cyanosis, so provide comfort and regular rest periods. Also, administer supplemental oxygen during cyanotic episodes.

Geriatric pointers

Because elderly patients have reduced tissue perfusion, peripheral cyanosis can present even with a slight decrease in cardiac output or systemic blood pressure.

Patient counseling

Teach patients with chronic cardiopulmonary diseases, such as heart failure, asthma, or COPD, to recognize cyanosis as a sign of severe disease; advise patients to get immediate medical attention when it occurs. If the patient is using oxygen at home, teach him how to use it properly.

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Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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