Which area should the nurse inspect when assessing for cyanosis in a dark skinned patient?

Could differences in skin color make a difference in how a person is diagnosed and treated? Experts say yes, it can, and yes, it often does. And unfortunately, that can lead to health disparities for minority populations.

Nurses care for people from a wide range of backgrounds and cultures – and a wide variety of skin colors, too. So, as a nurse, you must be aware of the role that skin color may play in healthcare.

“There are so many different shades of colors, even within each ethnicity or race,” said Phyllis Morgan, PhD, FNP-BC, CNE, FAANP, a faculty member for Walden University’s Master of Science in Nursing program. “It is important for nurses to be aware of different shades of color and how illnesses, infections, certain diseases may present themselves.”

“It is very important for nurses to be able to recognize how a client’s skin color may affect the presentation of signs and symptoms for various conditions,” agreed Danielle Leach, MSN, RNC-NIC, a faculty member at Arizona College of Nursing in Tempe, Arizona.

Making Patient Assessments That Are More Than Skin Deep

Don’t Make Assumptions

Every patient is different, and it’s important to remember that. “A nurse must be able to examine beyond the surface of each patient, regardless of their skin color,” says Morgan. “In essence, you can’t judge a book by its cover.”

So, a complete health history and thorough physical examination should be the order of the day with every patient, according to both Morgan and Leach.

“A client with darker skin may present with symptoms of hypoxia but may not appear pale or cyanotic at first glance,” she said. “If the nurse does not assess certain areas such as mucous membranes, where these characteristics may be more apparent, critical assessment information can be easily missed.”

Another example of a condition that may present differently, depending on the patient’s skin color: psoriasis.

This chronic skin condition affects about 125 million people worldwide, according to the National Psoriasis Foundation. It seems to affect white people more often, but some believe it may be underdiagnosed in people of color. Experts note that psoriasis often presents differently when it develops on darker skin, which may lead to misidentification. Instead of the red scaly patches of skin that appear on lighter colored skin, psoriasis plaques may take on a brown, gray or purple shade. Or the plaques may have a thicker layer of scales that makes it harder to get a good look at them. If a healthcare professional isn’t aware of these differences in presentation, they might miss them or downplay them.

Additionally, there are some special considerations for treatment of psoriasis in people of color. For example, phototherapy is sometimes recommended for psoriasis. However, in people with darker skin tones, it can sometimes cause patches of skin to darken and become more noticeable, according to the American Academy of Dermatology. They might prefer a different treatment as a result.

Educate yourself

Approaching each patient as an individual and not making assumptions can help avoid the possibility of missing something, but it’s also crucial for nurses to learn more about the role of skin color in healthcare.
In fact, it's an issue that will only grow in importance, since minority populations are expected to continue growing in the United States. The population that you will care for will be increasingly diverse.

“Taking time to educate yourself about the health of people from different ethnic and cultural backgrounds is vital to providing culturally competent and appropriate care,” Morgan said.

If you teach nursing students or mentor younger nurses, you might also take up the cause and look for opportunities.

Because textbooks have tended to show pictures of mostly Caucasian skin, Leach deliberately tries to incorporate pictures of patients with a variety of skin colors into presentations for her health assessment course so her students can see the differences. She also suggests that nurses seek out continuing education modules and peer-reviewed journal articles to learn more about the differences in skin color and how they can affect diagnosis and prognosis.

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A bluish color to the skin or mucous membrane is usually due to a lack of oxygen in the blood. The medical term is cyanosis.

Red blood cells provide oxygen to body tissues. Most of the time, nearly all red blood cells in the arteries carry a full supply of oxygen. These blood cells are bright red and the skin is pinkish or red.

Blood that has lost its oxygen is dark bluish-red. People whose blood is low in oxygen tend to have a bluish color to their skin. This condition is called cyanosis.

Depending on the cause, cyanosis may develop suddenly, along with shortness of breath and other symptoms.

Cyanosis that is caused by long-term heart or lung problems may develop slowly. Symptoms may be present, but are often not severe.

When the oxygen level has dropped only a small amount, cyanosis may be hard to detect.

In dark-skinned people, cyanosis may be easier to see in the mucous membranes (lips, gums, around the eyes) and nails.

People with cyanosis do not normally have anemia (low blood count). Anemia is a condition in which the body does not have enough healthy red blood cells.

Cyanosis that is seen in only one part of the body may be due to:

• A blood clot that blocks the blood supply to a leg, foot, hand, or arm
• Raynaud phenomenon (condition in which cold temperatures or strong emotions cause blood vessel spasms, which block blood flow to the fingers, toes, ears, and nose)

LACK OF OXYGEN IN THE BLOOD

Most cyanosis occurs because of a lack of oxygen in the blood. This can be caused by the following problems.

Problems with the lungs:

• Blood clot in the arteries of the lungs (pulmonary embolism)
• Drowning or near-drowning
• High altitude
• Infection in the smallest air passages in the lungs of children, called bronchiolitis
• Long-term lung problems that become more severe, such as chronic obstructive pulmonary disease (COPD), asthma, and interstitial lung disease
• Pneumonia (severe)

Problems with the airways leading to the lungs:

• Breath-holding (although this is exceedingly difficult to do)
• Choking on something stuck in the airways
• Swelling around the vocal cords (croup)
• Inflammation of the flap of tissue, called the epiglottis, that covers the windpipe (epiglottitis)

Problems with the heart:

• Heart defects that are present at birth (congenital)
• Heart failure
• Heart stops working (cardiac arrest)

Other problems:

• Drug overdose (narcotics, benzodiazepines, sedatives)
• Exposure to cold air or water
• Seizure that lasts a long time
• Toxins such as cyanide

For cyanosis caused by exposure to cold or Raynaud phenomenon, dress warmly when going outside or stay in a well-heated room.

Bluish skin can be a sign of many serious medical problems. Call or visit your health care provider.

For adults, contact your doctor or call the local emergency number, such as 911 if you have bluish skin and any of the following:

• You cannot get a deep breath or your breathing is getting harder, or faster
• Need to lean forward when sitting to breathe
• Are using muscles around the ribs to get enough air
• Have chest pain
• Are having headaches more often than usual
• Feel sleepy or confused
• Have a fever
• Are coughing up dark mucus

For children, contact the doctor or call the local emergency number, such as 911 if your child has bluish skin and any of the following:

• Hard time breathing
• Chest muscles moving in with each breath
• Breathing faster than 50 to 60 breaths per minute (when not crying)
• Making a grunting noise
• Sitting with shoulders hunched over
• Is very tired
• Is not moving around much
• Has a limp or floppy body
• Nostrils are flaring out when breathing
• Does not feel like eating
• Is irritable
• Has trouble sleeping

In general, cyanosis that occurs acutely is more likely to be an emergency than when it is present for a long time.

Your provider will perform a physical examination. This will include listening to your breathing and heart sounds. In emergency situations (such as shock), you will be stabilized first.

The provider will ask about your symptoms. Questions may include:

• When did the bluish skin develop? Did it begin slowly or suddenly?
• Is your body blue all over? How about your lips or nailbeds?
• Have you been exposed to cold or have you been at a high altitude?
• Do you have trouble breathing? Do you have a cough or chest pain?
• Do you have ankle, foot, or leg swelling?

Tests that may be ordered include:

• Arterial blood gas analysis
• Blood oxygen saturation by pulse oximetry
• Chest x-ray
• Chest CT scan
• Complete blood count (CBC)
• Electrocardiogram (ECG)
• Echocardiogram (ultrasound of the heart)

The treatment you receive depends on the cause of cyanosis. For example, you may receive oxygen for shortness of breath.

Lips - bluish; Fingernails - bluish; Cyanosis; Bluish lips and fingernails; Bluish skin

Fernández-Frackelton M. Cyanosis. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 11.

McGee S. Cyanosis. In: McGee S, ed. Evidence-Based Physical Diagnosis. 5th ed. Philadelphia, PA: Elsevier; 2022:chap 9.

Updated by: Denis Hadjiliadis, MD, MHS, Paul F. Harron, Jr. Associate Professor of Medicine, Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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