Integumentary & Lymphatics Flashcards
Lymphedema - Clinical Definition
What is lymphedema?
Where in the body is lymphedema most commonly observed?
Lymphedema refers to swelling (i.e., edema) of the soft tissues that results from the accumulation of a protein-rich, clear fluid called lymph in the interstitial spaces of tissue. (In lymphedema, the interstitial proteins continue to attract more water, contributing to progressively more edema.) Lymphedema is the consequence of lymphatic system failure due to decreased lymphatic transport capacity or increased lymphatic load.
- Lymphatic transport capacity refers to the maximum amount of lymph that the lymphatic system is able to transport.
- Lymphatic load refers to volume of lymph that the lymphatic system needs to transport throughout the body.
- *Note: The lymphatic system is primarily responsible for draining excess interstitial fluid as the lymph makes its way to the venous system (*see Vander’s [15th ed.], pp.407-408).
Lymphedema is most commonly seen in the extremities but can occur in the head, neck, abdomen, and genitalia.
References:
- Zuther and Norton (4th ed.), keywords: transport capacity, lymph volume
- Goodman and Fuller (4th ed.), p.673 (“Definition”)
- ECS II lecture: “Physical Therapy and Lymphedema, Part 1” (p.13)
- For more information about the stages of lymphedema, see Goodman and Fuller (4th ed.), p.673 (Box 13-1).
Secondary Lymphedema - Etiology
What causes secondary lymphedema?
Secondary lymphedema refers to lymphedema that occurs as the result of damage to otherwise normal lymphatic vessels or lymph nodes from a known entity.
Secondary lymphedema commonly occurs as a result of disruptions of the lymphatic system due to invasive procedures used in the diagnosis and treatment of cancer (e.g., regional lymph node dissection such as axillary node dissection associated with radical mastectomy; radiation therapy).
Reference:
- Goodman and Fuller (4th ed.), p.676 (“Secondary Lymphedema”)
Lymph Node
What is a lymph node?
What do normal and abnormal lymph nodes feel like?
Lymph nodes are rounded masses of lymphoid tissue that are surrounded by a capsule of connective tissue. Lymph nodes are distributed along the lymphatic vessels throughout the lymphatic system. The functions of the lymph nodes include:
- Filtering out harmful substances from the lymph (e.g., cancer cells, pathogens, dust, dirt)
- Production of a type of white blood cell called lymphocytes
- Reabsorption of water from the lymph
Normal lymph nodes are soft and nonpalpable. Abnormal lymph nodes (e.g., as in the presence of cancer involving lymph nodes) can be firm or hard, mobile or nonmobile, and tender or nontender.
References:
- Zuther and Norton (4th ed.)
- Merriam-Webster Dictionary: Lymph Node (https://www.merriam-webster.com/dictionary/lymph%20node)
- Goodman and Fuller (4th ed.), p.672 (“Lymph Nodes”)
Lymphedema - Clinical Presentation
What are the hallmark signs and symptoms of lymphedema?
- Full sensation in the affected body part
- A sensation of skin tightness
- Numbness, burning, or aching pain
- A feeling of heaviness in the limb or area
- Decreased flexibility in the hand, wrist, or ankle
- Difficulty fitting into shoes or clothing in one specific area
- Ring, wristwatch, or bracelet tightness
Reference:
- Goodman and Fuller (4th ed.), p.680 (“Clinical Manifestations”)
Lymphedema - Interventions
What physical therapy interventions are utilized to treat lymphedema?
The physical therapy treatment approach to lymphydema is called comprehensive lymphedema management (aka, complete decongestive therapy). Several components of comphrehensive lymphedema management include:
-
Manual lymph drainage (MLD). Manual lymph drainage is a gentle, manual treatment technique consisting of several basic strokes and is designed to improve the activity of intact lymph vessels by providing mild mechanical stretches on the wall of the lymph collectors, or the valve-containing tubes within the lymphatic system.
- The goal of MLD is to direct the lymph centrally toward the heart (i.e., right atrium).
- When completing MLD, mobilize the central (proximal) lymphatic pathways first (e.g., involved trunk quadrant), and then mobilize the peripheral (distal) lymphatic pathways (e.g., involved limb). When clearing the lymphatic pathways for the involved limb, mobilize the proximal segment first, and then mobilize the distal segment.
-
Compression bandaging to maintain the edema reduction achieved through MLD and prevent re-accumulation of fluid into the tissues
- Compression bandaging typically has a pressure gradient: pressure is greatest at the most distal point of the involved limb, and pressure gradually decreases as the bandage layers reach the proximal portion of the limb. This pressure gradient helps facilitate movement of lymph centrally toward the heart.
-
Exercises (e.g., ankle pumps, isometric contractions of large muscle groups) to use the skeletal muscle pump to assist with lymphangiomotoricity, or the ability of the lymphatic system to transport fluid
- Any exercise program for the individual with lymphedema must follow the basic concepts of the combined approach—that is, work the trunk muscles first, followed by the limb girdle muscles, working from proximal to distal on the limb, and finishing with trunk exercises and deep abdominal breathing to enhance flow through the thoracic duct.
References:
- Goodman and Fuller (4th ed.), p.667 (“Lymph Vessel Network”), 690 (“Physical Therapist’s Intervention”), 691 (“Manual Lymph Drainage”), 692 (“Long-stretch Compression Bandages”)
- Zuther and Norton (4th ed.)
- See ECS II, “Short-List for MLD Check-Out” Word doc.
Lymphedema - Precautions and Contraindications
What are precautions and contraindications associated with treatment of lymphedema?
- Avoid heat modalities as well as electrical stimulation that produce sustained tetanic muscle contractions.
- Heat modalities will increase superficial vasodilation and ultrafiltration, therefore increasing edema.
- Prolonged sustained tetanic muscle contractions caused by electrical stimulation can impair lymph flow in the area of skin overlying the muscle group, causing a retrograde edema distal to that site.
-
General contraindications to manual lymphatic drainage (MLD):
- Acute infection
- Metastatic cancer
- Unstable cardiac edema
- Acute deep vein thrombosis (DVT)
- Renal dysfunction
- Congestive heart failure
- *Pregnancy (*specific contraindication for MLD to the abdomen)
-
Contraindication to compression therapy:
- Ankle-brachial index (ABI) value of less than 0.8
- Indicates intermittent claudication or pathology related to occlusion of the arteries. Compression therapy will exacerbate ischemia and other effects of arterial occlusion.
- Ankle-brachial index (ABI) value of less than 0.8
References:
- Goodman and Fuller (4th ed.), p.686 (“Orthopedic Lymphedema”)
- See ECS II, “Short-List for MLD Check-Out” Word doc.
Basal Cell Carcinoma
What is basal cell carcinoma?
Basal cell carcinoma refers to a slow-growing surface skin tumor originating from undifferentiated epithelial cells called basal cells. Basal cell carcinoma is commonly the result of prolonged or intermittent sun exposure, and it is most commonly found on the head and neck. Basal cell carcinoma rarely metastasizes beyond the skin and does not invade blood or lymph vessels but can cause significant local destruction.
The hallmark signs of basal cell carcinoma include: (*see also image below)
- Pearly or ivory appearance
- Rolled edges
- Slightly elevated above the skin surface
- Small blood vessels on the surface (telangiectasia)
- Slow growth to 1-2 cm over many years
Reference:
- Goodman and Fuller (4th ed.), p.432 (“Basal Cell Carcinoma”), 433 (“Clinical Manifestations”)
Squamous Cell Carcinoma
What is squamous cell carcinoma?
Squamous cell carcinoma refers to a skin tumor originating from epithelial cells called keratinocytes, which are cells that produce the protein keratin. Squamous cell carcinoma is commonly the result of cumulative overexposure to UV radiation (e.g., outdoor employment or residence in a warm, sunny climate), and it commonly develops at the rim of the ear, the face, the lips and mouth, and the dorsal surfaces of the hands. Squamous cell tumors may be in situ (confined to the site of origin) or invasive (infiltrating surrounding tissue).
The hallmark signs of squamous cell carcinoma include: (*see also image below)
- Poorly defined margins
- Surrounded by scaly tissue
- Can present as an ulcer, a flat red area, a cutaneous horn, an indurated (hardened) plaque, or a nodule
- May be red to flesh-colored
Reference:
- Goodman and Fuller (4th ed.), p.434 (“Squamous Cell Carcinoma”)
Malignant Melanoma
What is malignant melanoma?
Malignant melanoma refers to a skin tumor that originates from melanocytes or cells that synthesize the pigment melanin. The most common type of malignant melanoma is superficial spreading melanoma. Malignant melanoma is commonly the result of excessive ultraviolet light exposure (e.g., exposure to tanning booths), and it commonly develops at the head and neck in men and the legs in women. Malignant melanoma usually is invasive and infiltrates surrounding tissue.
The hallmark signs of superficial spreading melanoma (mneumonic of ABCDE) include: (*see also image below)
- Asymmetry of shape
- Borders are irregular, jagged, and poorly defined
- Color variations (e.g., red, white, and blue; brown-black; black-blue)
- Diameter is bigger than a pencil eraser (e.g., larger than 0.5 cm)
- Evolving characteristics (e.g., size, shape, color) over time
References:
- See SJSU BIOL 65, “Embryology, Cells, and the Skin” Word doc.
- Goodman and Fuller (4th ed.), p.435 (“Definition and Overview”), 437 (“Clinical Manifestations”)
Nevus
What is a nevus?
A nevus (pl. nevi; aka, mole) refers to a new growth of skin tissue that develops when pigment cells (melanocytes) grow in clusters.
The hallmark signs and symptoms of nevi include: (*see image below)
- Round or oval in shape
- Smooth surface with a distinct edge
- Often dome-shaped
- Uniform color of pink, tan, or brown
- Smaller than 0.5 cm (i.e., the width of a pencil eraser)
Reference:
- NIH–National Cancer Institute: Common Moles, Dyplastic Nevi, and Risk of Melanoma (https://www.cancer.gov/types/skin/moles-fact-sheet#what-is-a-common-mole)
Pressure Injury
What is a pressure injury?
What are the primary guidelines for preventing pressure injuries?
Pressure injuries (formerly called bed sores, decubitus ulcer, pressure ulcer, pressure sore) refer to lesions caused by unrelieved pressure, resulting in damage to underlying tissue. Pressure injuries usually occur over bony prominences (e.g., heels, sacrum) and are staged to classify the degree of tissue damage observed (*see Goodman and Fuller [4th ed.], Figure 10-30 [p.461]; Box 10-12 [p.462]).
To prevent pressure injuries, patients will need to minimize the pressure over bony prominences (e.g., elevating the heel by placing foam cusions underneath the calf), and patients will also need to change their positions frequently:
- At least every 2 hours in bed
- At least every hour while sitting
- Every 15-20 minutes if the client can move himself or herself (e.g., pressure-relief activities such as leaning side-to-side, leaning forward, chair push-ups, tilt and recline system of a power-tilt wheelchair)
References:
- See DMGMC Lecture: Wound Care (p.31)
- Goodman and Fuller (4th ed.), p.460 (“Definition and Overview”), 467 (“Special Implications for the Therapist”)
- For information about pressure-relief activities, see DMNMC II spinal cord injury lecture (pp.59-62).
Tunneling and Undermining
Differentiate between tunneling and undermining.
How are tunneling and undermining measured?
Tunneling refers to channels or pathway that extend in any direction from the wound through subcutaneous tissue or muscle, resulting in dead space with potential for abscess formation.
Undermining refers to tissue destruction underlying intact skin along the wound margins or edges. In other words, undermining refers to the “caves” created at the margins or edges of the wound.
Tunneling and undermining are measured using the clock method for assessing the surface area of a wound (*see flashcard).
References:
- DMGMC Lecture: Wound Care (slide 50)
- Sussman and Bates-Jenson (4th ed.), p.87 (“Undermining and Tunnneling”)
Wound Assessment - Clock Method
What is the clock method for wound assessment?
The clock method is a technique used to assess the surface area of wounds. In this method, you imagine the wound as the face of a clock.
- Generally: 12:00 is the head, 6:00 is toward the feet, and 3:00 and 9:00 refer to either side of the body
- At the feet: 12:00 is the heel, and 6:00 is toward the toes
References:
- Sussman and Bates-Jenson (4th ed.), p.114 (“Choose a Consistent Method”)
- See DMGMC Lecture: Wound Care (p.47).
Age-Related Skin Changes
What are examples of age-related skin changes?
- Decreased sensation
- Decreased elasticity (turgor) of the skin
- Changes in skin pigmentation
- Decreased wound heaing due to reduced rate of epidermal proliferation
Wet-to-Dry Dressing
What is wet-to-dry dressing?
Wet-to-dry dressing refers to a mechanical debridment technique for necrotic tissues. Wet-to-dry dressing involves first placing a wet (or moist) gauze dressing on the wound and allowing the dressing to dry. Wound drainage and necrotic tissue can then be removed when the dressing is taken off the wound.
*Note: Wet-to-dry dressings are indicated if the wound has greater than 50% necrotic tissue.
References:
- MedlinePlus: Wet-to-dry dressing changes (https://medlineplus.gov/ency/patientinstructions/000315.htm)
- See DMGMC Lecture: Wound Care (p.73).
Define the following wound care terms:
- Lichenification
- Hypertrophic scarring
- Keloid scarring
- Epibole
- Lichenification refers to the process by which skin becomes hardened and leathery (lichenoid), usually as a result of chronic irritation (*from Merriam-Webster Dictionary).
- Hypertrophic scarring refers to thick fibrous tissue that remains within the original site of skin injury.
- Keloid scarring refers to growth of excessive scar tissue that grows beyond the boundaries of the original site of skin injury (*from Medscape: Hypertrophic Scarring and Keloids, https://emedicine.medscape.com/article/876214-overview#a2). The scar appears rubbery and smooth.
- Epibole refers rolled or curled-under closed wound edges with an open wound bed. Epibole develops when the upper epidermal cells roll down over the lower epidermal cells and migrate down the sides of the wound instead of across (*see DMGMC Lecture: Wound Care [p.58]).
