The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands which body area would provide the best assessment?
A. Lips
B. Sacrum
C. Earlobes
D. Back of the hands
Correct Answer: A. Lips
In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge. 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.
Option B: Skin color is particularly important in detecting cyanosis and staging pressure ulcers. Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels.
Option C: But 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. In patients with yellowish skin, cyanosis may cause a grayish-greenish skin tone.
Option D: When checking for pressure ulcers in dark-skinned patients, remember that dark skin rarely shows the blanch response. Instead, after applying light pressure, look for an area that’s darker than the surrounding skin or that’s taut, shiny, or indurated (hardened).
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