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Pallor

Pallor is abnormal paleness or loss of skin color, which may develop suddenly or gradually. Although generalized pallor affects the entire body, it’s most apparent on the face, conjunctiva, oral mucosa, and nail beds. Localized pallor commonly affects a single limb.

Skin color and the thickness and vascularity of underlying subcutaneous tissue affect the detection of pallor. Subtle lightening of skin color may be difficult to detect in dark-skinned persons — for example, the conjunctiva and oral mucosa may occasionally be the only areas in which pallor is evident.

Pallor may result from decreased peripheral oxyhemoglobin or decreased total oxyhemoglobin. The former reflects diminished peripheral blood flow associated with peripheral vasoconstriction or arterial occlusion or with low cardiac output. (Transient peripheral vasoconstriction may occur with exposure to cold, causing nonpathologic pallor.) The latter usually results from anemia, the chief cause of pallor. (See How pallor develops.)

Act Now: If generalized pallor suddenly develops, quickly look for signs of shock, such as tachycardia, hypotension, oliguria, and a decreased level of consciousness (LOC). Prepare to rapidly infuse fluids or blood. Keep emergency resuscitation equipment nearby.

Assessment

History

If the patient’s condition permits, take a complete history. Does he have a history of anemia or a chronic disorder that might lead to pallor, such as renal failure, heart failure, or diabetes? Ask about his diet, noting his intake of green vegetables.

Explore the pallor more fully. When did the patient first notice it? Is the pallor constant or intermittent? Does it occur when he’s exposed to the cold or when he experiences emotional stress? Investigate associated signs and symptoms, such as dizziness, fainting, orthostasis, weakness and fatigue on exertion, dyspnea, chest pain, palpitations, or loss of libido. Ask the female patient about menstrual irregularities. If the pallor is confined to one or both legs, ask the patient if walking is painful. Do his legs feel cold or numb? If the pallor is confined to his fingers, ask about tingling and numbness.

Physical examination

Start the physical examination by taking the patient’s vital signs. Be sure to check for orthostatic hypotension. Auscultate the heart for gallops and murmurs and the lungs for crackles. Check the patient’s skin temperature — cold extremities commonly occur with vasoconstriction or arterial occlusion. Also, note skin ulceration. Examine the abdomen for splenomegaly. Finally, palpate peripheral pulses. An absent pulse in a pale extremity may indicate arterial occlusion, whereas a weak pulse may indicate low cardiac output.

Pediatric pointers

In children, pallor can stem from a congenital heart defect or chronic lung disease.

Medical causes

Anemia

Typically, pallor develops gradually with anemia. The patient’s skin may also appear sallow or grayish. Other effects include fatigue, dyspnea, tachycardia, bounding pulse, atrial gallop, systolic bruit over the carotid arteries and, possibly, crackles and bleeding tendencies.

Arterial occlusion (acute)

Pallor develops abruptly in the extremity with the occlusion, which usually results from an embolus. A line of demarcation develops, separating the cool, pale, cyanotic, and mottled skin below the occlusion from the normal skin above it. Accompanying the pallor may be severe pain, intense intermittent claudication, paresthesia, and paresis in the affected extremity. Absent pulses and increased capillary refill time below the occlusion are also characteristic.

Arterial occlusive disease (chronic)

With chronic arterial occlusive disease, pallor is specific to an extremity — usually one leg, but occasionally, both legs or an arm. It develops gradually from obstructive arteriosclerosis or a thrombus and is aggravated by elevating the extremity. Associated findings include intermittent claudication, weakness, cool skin, diminished pulses in the extremity and, possibly, ulceration and gangrene.

Cardiac arrhythmias

Serious reductions in cardiac output caused by complete heart block and attacks of tachyarrhythmia may lead to pallor. Other features include an irregular, rapid, or slow pulse as well as dizziness, weakness and fatigue, hypotension, confusion, palpitations, diaphoresis, oliguria and, possibly, loss of consciousness.

Frostbite

Palloris localized to the frostbitten area, such as the feet, hands, or ears. Typically, the area feels cold, waxy and, perhaps, hard in deep frostbite. The skin doesn’t blanch and sensation may be absent. As the area thaws, the skin turns purplish blue. Blistering and gangrene may then follow if the frostbite is severe.

Orthostatic hypotension

With orthostatic hypertension, pallor occurs abruptly on rising from a recumbent position to a sitting or standing position. A precipitous drop in blood pressure, an increase in heart rate, and dizziness are also characteristic. At times, the patient loses consciousness for several minutes.

Raynaud’s disease

Pallor of the fingers upon exposure to cold or stress is a hallmark of Raynaud’s disease. Typically, the fingers abruptly turn pale and then cyanotic; with rewarming, they become red and paresthetic. With chronic disease, ulceration may occur.

Shock

Two forms of shock initially cause an acute onset of pallor and cool, clammy skin. With hypovolemic shock, other early signs and symptoms include restlessness, thirst, slight tachycardia, and tachypnea. As shock progresses, the skin becomes increasingly clammy, the pulse becomes more rapid and thready, and hypotension develops with narrowing pulse pressure. Other signs and symptoms include oliguria, subnormal body temperature, and a decreased LOC. With cardiogenic shock, the signs and symptoms are similar, but usually more profound.

Vasopressor syncope

The sudden onset of pallor immediately precedes or accompanies loss of consciousness during syncopal attacks. These common fainting spells may be triggered by emotional stress or pain and usually last only a few seconds or minutes. Before loss of consciousness, the patient may exhibit diaphoresis, nausea, yawning, hyperpnea, weakness, confusion, tachycardia, and dim vision. He then develops bradycardia, hypotension, a few clonic jerks, and dilated pupils with loss of consciousness.

Nursing considerations

If the patient has chronic generalized pallor, prepare him for blood studies and, possibly, bone marrow biopsy. If he has localized pallor, he may require arteriography or other diagnostic studies to accurately determine the cause.

When pallor results from low cardiac output, administer blood and fluids. The patient may also require a diuretic, a cardiotonic, and an antiarrhythmic. Frequently monitor his vital signs, intake and output, electrocardiogram results, and hemodynamic status.

Patient teaching

If the patient’s pallor is related to anemia, explain the importance of an iron-rich diet and rest. If he has pallor due to frostbite or Raynaud’s disease, inform him about cold protection measures. If pallor is related to orthostatic hypotension, explain the need to stand up slowly and to sit down when dizziness occurs.

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Book Source Details

• Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-624-5

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