Integumentary Unit Flashcards

1
Q

Where does the lymphatic system empty into the venous system?

A

left subclavian vein; the area where the venous system pressure is the lowest

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2
Q

Role of the lymphatic system

A
  • immune surveillance
  • balance fluids and proteins in the circulatory system by transporting lymph fluid
  • assists in fat digestion
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3
Q

How is excess body fluid disposed of/excreted?

A

in the urine

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4
Q

Transport capacity

A

the body’s ability to transport fluid away from an area; 10-30% in the lymphatic system

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5
Q

Lymph fluid movement

A

peripheral to central

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6
Q

Mechanisms of lymph transport

A
  • contraction of the lymphangions
  • active and passive body movements
  • arterial pulsation
  • muscle pump
  • manual therapy techniques
  • respiration
  • “vis a tergo”
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7
Q

What is the rate of contraction of the lymphangions?

A

6-10 bpm

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8
Q

Primary lymphedema

A
  • congenital/hereditary
  • impaired vessel development
  • leg > arm
  • distal > proximal
  • female > male (9:1)
  • asymmetrical
  • 83% manifest before 35 YOA
  • onset usually at puberty
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9
Q

Secondary lymphedema

A

damage to the lymphatic system d/t:

  • trauma
  • surgery
  • radiation
  • inflammation
  • malignancy
  • CVI
  • filariasis
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10
Q

What are the main causes of LE in the western world?

A
  • breast CA
  • skin CA
  • reproductive system CA
  • prostate CA
  • trauma
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11
Q

What is the primary cause of LE in developing countries?

A

filariasis

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12
Q

Known predictors of LE onset

A
  • surgical dissection of nodes/organs
  • radiation therapy
  • age
  • obesity/increased body weight
  • injury/infection via dermal wounds
  • local hyperemia caused by exercise, heat, modalities
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13
Q

“Limb at risk”

A
  • refers only to the involved extremity
  • a lifelong condition
  • careful lifestyle choices
  • potentially a latency period between injury and clinical appearance of lymphedema
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14
Q

Changes in altered system

A
  • excess protein in tissues
  • excess fluid in the limb
  • decreased oxygenation
  • slow healing time
  • formation of fibrosis-proteins = “joiners”
  • lymphangions get clogged
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15
Q

Class I - Mild LE

A

less than 3 cm difference between limbs

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16
Q

Class II - Moderate LE

A

3-5 cm difference between limbs

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17
Q

Class III - Severe LE

A

5+ cm difference between limbs

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18
Q

Prevention and control of LE

A
  • skin care
  • exercise
  • maintain a healthy weight
  • precautions
  • seek early treatment (esp. if changes last longer than 1 wk)
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19
Q

Complete Decongestive Therapy - Phase 1

A
  • MLD
  • lymphedema bandaging
  • skin care
  • exercise
  • compression garment at the end of phase 1
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20
Q

Manual Lymph Drainage

A
  • increases frequency of vessel contractions
  • increases the volume of lymph that is transported
  • increases pressure in the vessels
  • can reverse the direction of lymph flow
  • enhances local arterial blood flow
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21
Q

Lymphedema Bandaging

A
  • encourages lymph vessels to empty through a mild increase in tissue pressure
  • prevents refilling of interstitium between treatments
  • provides essential support for tissues
  • improves the efficacy of the muscle pump during exercise/movement
  • softens fibrotic tissue through pressure
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22
Q

Exercise

A
  • increases lymph vessel contraction rate
  • improves lymph fluid circulation
  • improves the efficiency of thoracic duct via deep breathing
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23
Q

Compression Garments

A
  • prevent refilling of the interstitium
  • preserve limb reduction long-term
  • support tissues that have lost elasticity
  • must be worn to retain reduction of limb size
  • worn during the day (bandage at night)
  • most patients must wear for the remainder of life
24
Q

Skin Care

A
  • prevents accumulation of bacteria
  • helps prevent the onset of cellulitis
  • supplies moisture to dry skin
  • protects against sunburn, scrapes, cuts and other risks for infection
25
Best practice during phase 1
- treatment time: 60-120 min - 5 days/week - 2-6 weeks for moderate symptoms - 8-18 weeks for severe symptoms - self or family wrap by day 5 - patient purchases bandages online
26
CDT Phase 2
- a compression garment - home exercise - bandaging - skin care - MLD if appropriate
27
Contraindications to CDT
- uncompensated cor pulmonale - acute infections: local or systemic, viral or bacterial - acute venous thrombosis - ongoing radiation treatments - wait 6 weeks after radiation is completed or until skin returns to normal color - conditions related to acute fluid management - cardiac, pulmonary, and renal insufficiency
28
Relative Contraindications to CDT
- cor pulmonale - implants such as pacemakers, venous ports - radiation damage to skin, other diseases - malignant melanoma, malignant lymphedema - conditions related to chronic fluid management - cardiac, pulmonary, and renal insufficiency
29
Reasons LE treatment doesn't work
- lack of patient adherence - insufficient treatment: too late, not enough visits, not enough MLD, too few bandages, inexperienced therapist - comorbidities - unrealistic expectation of rapid outcome - malignant lymphedema
30
Allyson
- primary lymphedema - LE swelling at birth that worsened with age - had difficulty with self-esteem during middle school - felt more confident once she learned to manage her condition - studied abroad in Peru - Graduated from Colorado St.
31
Tammy
- survivor of stage III tongue CA - surgery to rebuild tongue - reoccurred in palate and tonsils - experienced chemo and radiation - caused swelling in face and neck - rebuilt tongue muscle with upper trapezius, which caused shoulder problems - was referred to an OT at the University of Michigan for secondary lymphedema - used a machine that had immediate effects on her d/t the reduction of fibrosis - pulls dermal and epidermal away from fascial tissues with vertical and horizontal forces - works in criminal justice
32
Stephanie
- Marengo, IL - experienced obesity for most of her life - worsened during high school - began noticing problems in 2008 - was hospitalized with symptoms of Hashimoto's disease - was treated with Lasix for three years, which made her legs much worse - a therapist tried short stretch compression bandaging, but not MLD, then gave her OTC compression garments - reached 520 lbs. in 2010 - underwent gastric surgery in 2013 - chose to have her left leg treated first - treatment gave her a purpose - BMI 67.8 down to 38.0 - she got married in 2014
33
T/F: Lymphedema is not painful
True
34
Inspection
- location of swelling - skin changes (i.e. color, texture) - scar tissue, radiation damage - lymphatic cysts, fistulas, other
35
Palpation
- temperature differences on the surface - pitting edema - fibrosis of underlying tissue - moist vs. dry with palpation
36
Characteristics of DVT
- sudden onset, usually unilateral - pain - cyanosis or rubor and heat - positive Homan's sign - dx with Doppler US
37
Characteristics of CHF and Cardiac edema
- greatest distally - always bilateral - pitting edema - nearly complete resolution with elevation - no pain - hx consistent with CHF - may be SOB - meds for CHF
38
Characteristics of Renal Failure
- kidneys unable to remove waste - fatigue - flank pain between ribs and hips - swelling of ankle, foot, leg - changes in urination (increased/decreased/stopped)
39
Characteristics of malignancy
- pain, paresthesia, paralysis (rare) - proximal onset - rapid development, progressive - swelling in the supraclavicular fossa - could be purple discoloration - non-healing open wounds - hx of malignancy - pain that wakes them up at night - unusual fatigue and/or weight loss
40
Characteristics of infection
- acute: warm, red, burning, edema, pain, sweating, red streaks in the skin, systemic symptoms, fever - chronic: warm or cool, pale or red, edema, pain, little fever if any - eventual fibrosis, osteomyelitis, skin breakdown, rash
41
Post-op complications
- possible acute DVT - more than normal inflammation - infection - excess bleeding - symptoms from poor positioning - swelling as side effect of tourniquet
42
Characteristics of CRPS
- acute: warm, red, burning, edema, pain, sweating - chronic: cool, pale, edema, pain, dry eventual fibrosis, osteoporosis, atrophy of skin and muscle
43
Characteristics of lymphedema
- slow onset, progressive - pitting in early stages - begins distally - cellulitis in hx is common - rarely painful but the swelling is uncomfortable - heavy, aching discomfort - skin changes - ulcerations unusual unless CVI is present
44
Characteristics of Lipedema
- a disorder of adipose tissue - the condition may be inherited - almost always female - women of all sizes, upper body can be normal size - excess deposit of fat cells - fatty tissue does not respond well to diet and exercise - can appear COMBINED with lymphedema - bilateral, symmetrical swelling: iliac crest to ankles - swelling spares the dorsum of feet - little/no pitting - no hx of cellulitis - painful upon palpation - can trigger 2˚ lymphedema
45
Characteristics of CVI
- non-pitting - hemosiderin staining - fibrosis of subcutaneous tissue - atrophic skin (poor quality) - usually ankle to the knee at most - wounds common - can trigger 2˚ lymphedema
46
Characteristics of CVI
- non-pitting - hemosiderin staining - fibrosis of subcutaneous tissue - atrophic skin (poor quality) - usually ankle to the knee at most - wounds common - can trigger 2˚ lymphedema
47
Characteristics of Baker's cyst
- fluid filled cyst behind knee - causes a bulge that is often visible - may cause LE swelling - the feeling of tightness - pain with activity in flexion/extension
48
Characteristics of myxedema
- thyroid dysfunction - dry skin - brittle nails - thinning hair - decreased sweat - orange tint to the skin - deposition of mucinous substances in the skin (eyelids, face, elsewhere)
49
Cyclical Idiopathic Edema
- periodic swelling/bloating in the legs/abdomen - occurs in women while standing - disappears when laying down - happens most often before the menstrual period - rule out cardiac, kidney, liver disease
50
Characteristics of edema
- often rapid onset, may be progressive - pitting in early stages - begins at the injury, insult, or surgery site - cellulitis is NOT common in hx - usually painful until 2 weeks out - heavy, aching discomfort - rarely have skin changes due to acuteness - ulcerations unusual unless CVI - bruising common
51
Diagnostic tests for LE
- gold standard: physical exam and hx - lymphography - venous doppler - lymphoscintigraphy - CT scan - MRI - rule out heart, kidney, lung, liver, reproductive system
52
Phlebolymphedema
a combination of CVI and lymphedema; must be compressed
53
Watersheds
where lymph nodes runs toward
54
Poor postures that obstruct lymph flow
- crossing legs while seated - sleeping on stomach - sitting too long without break (flexed hips and knees) - keyboarding too long without breaks (flexed elbows) - driving without appropriate rest breaks
55
MLD Pattern
neck - abdomen - ipsilateral adjacent nodes - contralateral nodes - affected nodes - affected limb