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.

How easily pallor is detected varies with skin color and the thickness and vascularity of underlying subcutaneous tissue. At times, it’s merely a subtle lightening of skin color that may be difficult to detect in dark-skinned persons; sometimes it’s evident only on the conjunctiva and oral mucosa.

Pallor may result from decreased peripheral oxyhemoglobin or decreased total oxyhemoglobin. The former reflects diminished peripheral blood flow associated with peripheral vasoconstriction, arterial occlusion, or 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, page 482.)

Emergency Actions

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

History

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

Then explore the pallor more fully. Find out when the patient first noticed it. Is pallor constant or intermittent? Does it occur when he’s exposed to the cold? Does it occur when he’s under emotional stress? Explore associated signs and symptoms, such as dizziness, fainting, orthostasis, weakness and fatigue on exertion, dyspnea, chest pain, palpitations, menstrual irregularities, or loss of libido. 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 assessment

Start the physical assessment 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.

CULTURAL CUE:Because skin color varies according to race and ethnic background, establish a baseline skin color so that changes can be more readily detected.

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

Cardiac arrhythmias that seriously reduce cardiac output, such as complete heart block and attacks of tachyarrhythmia, may cause acute onset of pallor. Other features include irregular, rapid, or slow pulse; 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 if the frostbite is deep. 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 hypotension, 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, then cyanotic; with rewarming, they become red and paresthetic. With chronic disease, ulceration may occur.

Shock

Two forms of shock initially cause 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, pulse becomes more rapid and thready, and hypotension develops with narrowing pulse pressure. Other signs and symptoms include oliguria, subnormal body temperature, and decreased level of consciousness. With cardiogenic shock, the signs and symptoms are similar, but usually more profound.

Vasopressor syncope

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.

Special considerations

If the patient has chronic generalized pallor, prepare him for blood studies and, possibly, bone marrow biopsy. If the patient 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 as well as a diuretic, a cardiotonic, and an antiarrhythmic, as needed. Frequently monitor the patient’s vital signs, intake and output, electrocardiogram results, and hemodynamic status.

Pediatric pointers

In children, pallor stems from the same causes as it does in adults. It can also stem from a congenital heart defect or chronic lung disease.

Patient counseling

Teach the patient with anemia to eat foods rich in iron and to plan periods of rest throughout the day. Advise the patient with frostbite and Raynaud’s disease to dress appropriately in cold weather and to limit time outdoors. Tell the patient with orthostatic hypotension or syncope to rise slowly from a recumbent to a standing position.

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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.

Other Book Chapters Related to Pernicious anemia

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Pernicious anemia: Introduction (review 24 causes)
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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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