In addition to tachycardia, wide pulse pressure, and hyperdynamic precordium, a systolic ejection murmur is often heard over the precordium, particularly at the pulmonic area. In addition, a venous hum may be detected over the neck vessels. These findings disappear when the anemia is corrected. Show
View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9781437716047001615 Pallor and AnemiaAmanda M. Brandow, in Nelson Pediatric Symptom-Based Diagnosis, 2018 IntroductionPallor, a perceptible reduction in the usual color and tone of the skin and/or mucosa, may result from alterations of cutaneous blood flow, anemia, or unknown mechanisms. Under normal circumstances the pink appearance of the lips, mucosa, and skin is influenced by the nature and character of these tissues, the adequacy of vascular perfusion, and the level of hemoglobin. Pallor is a highly nonspecific finding that may be a manifestation of a diversity of diseases or it may be normal for a given individual. Parental perception of pallor frequently generates considerable anxiety. Although pallor is most often intuitively associated with anemia by families and physicians, a broad diagnostic perspective is appropriate (Table 37.1). Anemia is the condition in which hemoglobin level (or hematocrit) is more than 2 standard deviations below the mean for age. Anemia is clinically relevant only when the low hemoglobin level results in decreased oxygen-carrying capacity of the blood. By definition, 2.5% of the general population has a hemoglobin or hematocrit level below the defined limits of normal. This fact must be kept in mind when evaluating children with mild anemia for which no explanation can be identified. Hemoglobin level varies considerably with age and sex (Table 37.2). Newborns have relatively high levels of circulating hemoglobin due to intrauterine adaptation to a relatively hypoxic environment. During the 1st 2 months of life, hemoglobin production markedly diminishes and a physiologic nadir occurs. The mean hemoglobin level rises gradually during childhood equally for both boys and girls until puberty when boys achieve a level approximately 20% higher than that of girls. Anemia occurs as the result of 1 or a combination of 3 pathophysiologic mechanisms: •Acute blood loss •Impaired bone marrow production of red blood cells (RBCs) •Increased peripheral destruction of RBCs (hemolysis) Under normal conditions, the body's RBC mass is maintained at a level appropriate to support tissue oxygen needs through the oxygen-sensing regulatory feedback stimulus of the hormone erythropoietin. Produced in the kidney, erythropoietin stimulates the production of mature RBCs within the bone marrow. Over a 3- to 5-day period, RBC precursors mature into reticulocytes that are released into the peripheral blood. In 24-48 hours, reticulocytes become mature RBCs that circulate in the peripheral blood for approximately 120 days. Senescent RBCs are removed from the circulation by reticuloendothelial cells within the spleen, liver, and bone marrow. A metabolic by-product of hemoglobin catabolism is bilirubin. HistoryThere are several important aspects of the history that can assist in the evaluation of a patient with pallor and suspected anemia. A child with pallor is not necessarily anemic. Assessment of sun exposure and familial patterns of complexion are crucial because many patients are intrinsically pale. A careful evaluation of the medical history is fundamental in the assessment of a patient with suspected pallor (Table 37.3). Obtaining a dietary history is very important when evaluating a patient for anemia. Infants delivered prematurely or exclusively breast-fed infants without adequate iron supplementation from infant foods in the 2nd half of their 1st year of life are at risk for iron or iron deficiency anemia. Toddlers who consume large amounts of cow's milk and children and adolescents who consume little meat are also at risk for iron deficiency anemia. In addition, patients and breast-fed infants of mothers who follow a strict vegan diet may become deficient in vitamin B12. A neonatal history of hyperbilirubinemia supports a possible diagnosis of congenital hemolytic anemia such as hereditary spherocytosis. This can be further supported by a family history of anemia, blood transfusions, splenectomy, and/or cholecystectomy. Medication history is pertinent because certain drugs, including antimalarial agents and sulfonamide antibiotics, can induce oxidant-associated hemolysis in the patient deficient in glucose-6-phosphate dehydrogenase (G6PD), whereas other medications may cause immune hemolysis (penicillin) or decreased RBC production (chloramphenicol). Travel history may suggest exposure to infections such as malaria. Physical ExaminationThe general appearance of the child can provide clues to the severity and chronicity of the problem. Severe anemia that develops slowly over weeks or months is often well tolerated. Vital signs (including orthostatic blood pressure), height, weight, and growth offer further insight into the severity of the problem. Isolated pallor in a well-appearing child who does not have evidence of systemic disease is usually much less ominous than pallor noted in a child who is ill-appearing, has bruising, petechiae, lymphadenopathy, hepatosplenomegaly, or abdominal mass. Pallor at any site increases the likelihood of anemia; pallor of the face, nail beds, tongue, palms and palmar creases as well as conjunctival pallor enhance the likelihood of anemia. Conjunctival rim pallor when compared to the usually more fleshlike pallor of the deeper posterior region of the palpebral conjunctiva is highly specific in adult patients with anemia. Table 37.4 outlines physical examination findings that may provide clues to the underlying cause of the anemia. Prominent cheekbones, dental malocclusion, and frontal bossing may occur in patients with chronic hemolytic anemias (i.e., thalassemia major) because of the expansion of bone marrow space. Tortuosity of conjunctival vessels occurs in sickle cell disease. Splenomegaly is often present in children with congenital hemolytic anemia. Lymphadenopathy and hepatosplenomegaly may indicate the presence of infiltrative disease of the bone marrow and visceral organs such as leukemia. Purpura in the anemic child is suggestive of associated thrombocytopenia that may accompany aplastic anemia or leukemia. Many congenital anomalies and/or dysmorphic features have been associated with hematologic syndromes. Patients with Fanconi anemia are often short, have hyperpigmentation, hypoplastic “finger-like” thumbs, radial bone anomalies, and structural renal abnormalities. Patients with Diamond–Blackfan anemia are often short and have a “curious, intellectual” facial expression. When pallor and anemia are seen in the context of other signs that suggest chronic inflammation, infection or systemic disease, a diligent general physical examination may yield substantive information. Hypertension and short stature may suggest chronic renal disease. Joint swelling and/or pain may suggest rheumatologic disorders. Digital clubbing may suggest advanced cyanotic cardiopulmonary diseases. Abdominal pain, diarrhea, and poor growth may suggest inflammatory bowel disease. Recent onset of pallor is suggestive of anemia. The child who has always appeared somewhat pale but is otherwise well with normal growth and development likely has an intrinsic constitutional characteristic. In such instances, the child and other family members often have light hair and skin complexion. An unremarkable general medical history and physical examination support a physiologic explanation for pallor. Some children may appear pale as a result of limited sun exposure as might occur during the winter in cooler climates. Children with malignant disease or chronic illness (e.g., rheumatologic disorders, inflammatory bowel disease, chronic cardiopulmonary disorders, diabetes) may have a pale appearance that is unrelated or out of proportion to the degree of associated anemia. Atopic children often have distinctly pale mucosa as a result of local edema. Children with generalized edema caused by hypoproteinemia, congestive heart failure, or vasculitis often appear pale as a result of excess interstitial fluid within the mucosal or cutaneous tissues. Patients with hypothyroidism are pale because of myxedematous changes in the skin, subcutaneous tissue, and mucosa. Laboratory EvaluationThe initial laboratory test in a child with pallor should be a complete blood cell count (CBC) including a manual white blood cell (WBC) differential. Significant pallor from anemia usually does not occur until the hemoglobin level falls below 8 g/dL. “False anemia” (resulting from laboratory error, sampling difficulty, or “statistical anemia”) should be considered whenever a child is said to be anemic and laboratory findings are not consistent with clinical impressions. Capillary blood sampling can be associated with substantial error, depending on the difficulty in performing the procedure and the use of mechanical force necessary to promote blood flow. When laboratory or sampling errors are suspected, a venipuncture sample should be obtained for confirmation. By definition, 2.5% of the general population has hemoglobin levels below the lower limit of normal, which is termed “statistical anemia.” This phenomenon should be considered when mild, unexplained normocytic anemia is identified in a healthy child. Almost all laboratories perform CBCs with automated technology systems. Hemoglobin level (grams per deciliter), RBC count (cells per cubic millimeter), and mean corpuscular volume (MCV) (expressed in femtoliters [fL]) are directly measured. Hematocrit value, mean corpuscular hemoglobin (MCH), and MCH concentration (MCHC) are derived values and therefore are less accurate. Other important information reported includes RBC distribution width (RDW), WBC count (cells per cubic millimeter), and platelet count. In addition to the hemoglobin values, careful attention should be given to the MCV, RDW, RBC morphology, platelet count, and WBC count. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323399562000376 Etiology and Natural HistoryJohn Byrne MCh FRCSI (Gen), in Comprehensive Vascular and Endovascular Surgery (Second Edition), 2009 PallorPallor indicates obstruction of a major arterial trunk to the leg. In the absence of collateral circulation, this produces a marble white, waxy leg with absent capillary refill and collapsed veins or “venous guttering” (Figure 13-1). The leg may even appear cadaveric. In arterial thrombosis, initial pallor may be followed by gradual improvement, with return of skin perfusion and capillary refill, over 6 to 12 hours due to opening of preformed collaterals. Capillary refill on blanching the skin indicates that the leg is still retrievable, even if the foot is mottled and cyanosed. However, fixed mottling and fixed staining (cyanosed or purple areas of skin that fail to blanch on pressure) indicate that the capillaries have thrombosed and ruptured. Such limbs are unsalvageable. Fixed staining may also be seen in synergistic gangrene, especially gas gangrene. These patients often are septic, and the relative warmth of the affected leg and the finding of crepitus are important differentiating clinical signs. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780323057264000159 Neuro-Ophthalmic Manifestations of CraniopharyngiomasRobert C. Sergott, in Craniopharyngiomas, 2015 Optic Disc Pallor and Optical Coherence TomographyPallor of the optic disc invariably develops following any pathological process affecting the optic nerve, chiasm, and optic tract. Many studies have been undertaken to determine whether the presence of optic disc pallor can predict recovery of visual function after resection of craniopharyngiomas. No definitive conclusions can be made about the predictive value of pallor, probably because of the subjective nature of this assessment. Spectral domain optical coherence tomography (SD-OCT) offers greater promise for predicting visual outcome after surgery. SD-OCT uses confocal laser imaging and inferometry to quantify the number of unmyelinated axons in each optic nerve (Figure 6.4). Likewise, SD-OCT also can measure the thickness of all the layers of the retina. These structural parameters are complimentary to visual acuity, visual field, and color vision testing and do not replace these functional metrics. A report about time domain OCT has supported this concept. SD-OCT is much more sensitive and reproducible than time domain OCT, and therefore may provide even more accurate metrics for predicting visual acuity and visual field recovery post-operatively (Danesh-Meyer et al., 2006).  FIGURE 6.4. Spectral domain optical coherence tomogram (SD-OCT) of patient with bilateral axon loss due to chiasmal compression from the pituitary adenoma. The upper image illustrates the area imaged around the optic nerve in each eye, and the middle image shows how the SD-OCT isolates the retinal nerve fiber layer. The colored circular maps indicate that the patient has a nerve fiber layer thickness that is two standard deviations less than expected from age- and gender-matched data. When reduced retinal nerve fiber layer thickness is present pre-operatively, patients seem to be less likely to recover vision after surgical removal of the mass lesion. View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B9780124167063000064 Neuro-ophthalmologyAlfredo A. Sadun, Michelle Y. Wang, in Handbook of Clinical Neurology, 2011 Differential diagnosisAcquired temporal pallor describes segmental optic atrophy, usually appearing as a sharply demarcated wedge defect secondary to papillomacular bundle lesions. In contrast, superior, inferior, or nasal pallor is rarely as sharply demarcated. Acquired temporal pallor is usually caused by pathologies affecting the central visual field such as LHON, autosomal-dominant optic neuropathy, toxic and nutritional optic neuropathies, and optic neuritis. In contrast, superior or inferior disc pallor is often caused by ischemic processes (e.g., anterior ischemic optic neuropathy). Optic chiasmal syndrome with bitemporal hemianopic fields has eyes demonstrating optic atrophy mostly in the nasal and temporal regions of the disc. Therefore, the optic pallor is described as “band” or “bow-tie” atrophy (Fig. 5.8), affecting primarily nasal and temporal regions with preservation of the superior and inferior regions of the disc (Unsöld and Hoyt, 1980). Fig. 5.8. Bow-tie atrophy. Note the horizontal band of atrophy in the nasal and temporal regions of the disc with preservation of the superior and inferior regions of the disc. It is important to keep in mind that the presence of pallor is meaningful only when it is correlated with optic nerve function. A mildly pale disc with normal function is most likely physiological rather than pathological. This is especially true if the pallor is confined to the temporal side. Conversely, a normal-appearing disc with severe optic nerve dysfunction requires more careful evaluation (Fig. 5.8). View chapterPurchase book Read full chapter URL: https://www.sciencedirect.com/science/article/pii/B978044452903900011X Toxic effects of metalsP.K. Gupta, in Fundamentals of Toxicology, 2016 Chronic Poisoning (Plumbism, Saturnism)Chronic poisoning with lead compounds may lead to the following: Facial Pallor: Pallor that is seen especially around the mouth. It is also known as circum oral pallor and is due to the vasospasm of the capillaries and arterioles around the mouth. •Anemia: Hypochromic, microcytic anemia with reticulocytosis and punctuate basophilia with the presence of marked basophilic stippling in the RBCs. Platelet count decreases. Anemia is probably due to decreased survival time of RBCs and inhibition of heme synthesis by interference with the incorporation of iron into protoporphyrin. •Burtonian line (lead line): A stippled blue line seen at the junction of the gums, usually nearer to tooth caries, especially in the upper jaw. This is due to the deposition of lead sulfide formed by the action of the combination of lead sulfide formed by the action of the combination of lead with hydrogen sulfide, which evolved from the decomposed food debris in the caries tooth. •Lead colic and constipation: The victim will report severe colicky pain in the abdomen relieved by pressure and bowel irregularities. Abdominal muscles become tense and retracted. •Lead palsy: A typical paralysis affecting the extensor muscles of the fingers and wrist causing wrist drop and claw-shaped hand. Similarly, paralysis may extend to the extensor muscles of the foot, leading to foot drop. •Lead encephalopathy: Mostly seen in infants presenting with severe ataxia, vomiting, lethargy, stupor, convulsion, and coma; cerebral psychic effects may be present. •Cardiorenal manifestations: Elevated blood pressure and arteriosclerotic changes are observed. Urine contains albumin and an abnormal quantity of lead, coproporphyrin III, and delta amino laevulinic acid. Interstitial nephritis may occur. •Sterility/infertility: Both may be observed. •General manifestations: These include weakness, anorexia, metallic taste in the mouth, dyspepsia, and foul breath. Which condition would cause a light skinned patients skin tone to be whitish pink in color?Vitiligo Vitiligo, or leukoderma is a chronic autoimmune disease that causes loss of pigment in the skin, resulting in white or discolored patches.
What signs of cyanosis does a nurse inspect for in a darkBut in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish.
How does the nurse recognize jaundice in a darkThe most obvious sign of jaundice is a yellow tinge to the skin and the whites of the eyes. The yellowing of the skin is usually first noticeable on the head and face, before spreading down the body. In people with dark skin, yellowing of the whites of the eyes is often more noticeable.
Where should the nurse assess a darkIn 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).
|
Which change in skin tone would the nurse observe in a light-skinned patient with anemia?
zusammenhängende Posts
Urheberrechte © © 2024 decemle Inc.
