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NPTE Final Frontier > Lymphatics > Flashcards

Lymphatics Flashcards

1
Q

Lymphatic system:
What is Lymph?

A
  • Portion of interstitial fluid entering the lymphatic system
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2
Q

Lymphatic organs

A

Nodes, tonsils, thymus, thoracic duct, bone marrow

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3
Q

MAJOR lymph nodes

A
  • submax, iliac, mesenteric, inguinal, popliteal, supraclavicular, parasternal
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4
Q

Lymphatic system we think of what?

A

Immune system
Infx’s fighter

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5
Q

Flow of Lymph:

Think SMALL to BIG (all ends up in Subclavian veins)

A
  1. FROM lymphatic capillaries
  2. Lymphatic collecting vessels
  3. Lymph nodes (filter lymph)
  4. Lymphatic trunks
  5. Lymphatic ducts
  6. Subclavian veins INTO bloodstream
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6
Q

So you know the flow of Lymph. Now where does it get drained? MAJORITY vs RUE/Face?

A
  • ENTIRE L. SIDE and B/L LE’s drained by Thoracic duct
  • RUE/Face (ONLY HERE) drained by Lymphatic duct
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7
Q

Lymphatic Load:
aka how much present

A

AMT of lymph fluid transported

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8
Q

Transport capacity–>
aka HOW MUCH can be transported

A

MAX amt of fluid that lymphatic system CAN TRANSPORT

Bw the two (Load vs Capacity): INC load + DEC capacity==> Lymphedema

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9
Q

INC lymphatic load + DEC transport cap== Lymphedema

Give some ex’s

A
  1. Venous insuff. + blood pooling==> INC lymphatic LOAD (no pump blood, accumulation)
  2. Lymph node removal==> DEC transport capacity
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10
Q

What is Lymphedema?

A
  • CHRONIC disorder, abnormal accumumulation of lymph in the tissues of one or more body regions
  • NOTE: 2 types (Primary vs 2*)
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11
Q

Primary Lymphedema==>

A

ALWAYS been there
Congenital or hereditary

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12
Q

Secondary Lymphedema ==>

A

Injury to one or more components of lymph system
EX. lymph node removal

caps-vessels-nodes-trunks-ducts-SubC veins

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13
Q

Practice!!
76yo female w/ dx of SECONDARY lymph. Pt states she had breast cx last year w/ sx to remove cx. All of these COULD be causes of secondary lymph.

A
  • infx
  • fibrosis
  • Chronic venous insuff.

NOTE: If you see Milroys– this is primary/congenital cause= Primary

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14
Q

Severity of Lymphedema
How is Severity described?

A

Severity of changes that occur in the skin, and subQ tissues

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15
Q

Severity of Lymphedema
Looking @ Edema (severity lvls)
Summarize each

Severity inc’ing from Pitting–> Weeping

A
  • Pitting-“makes a pit”–short duration edema w/ little or NO fibrotic changes in skin or SubQ
  • Brawny (strong guy, feels hard)– NO PIT. More severe form of swelling w/ progressive, fibrotic changes in SubQ
  • Weeping (crying, leaking)– MOST severe, LONG duration. Fluid leaks cuts/sores–sig impaired wound healing–> EXCLUSIVELY in LEs
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16
Q

(+) Stemmer Sign in a nutshell…

A

CANNOT PINCH THE SKIN

==> WORSENING OF CONDITION

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17
Q

Stemmer Sign KNOW IT!

A

(+) = Stage II or III Lymph.
(+)= dorsal surf. of skin cannot be pinched (lifted) vs uninvolved
==> Worsening

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18
Q

Stages of Lymphedema

Lymph03dema

A

4 Stages total:
**Staged 0-3 **

Lymph03dema

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19
Q

Stages of Lymph03dema

0(best)-3(worst)

A

ALL HERE

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20
Q

Lymph03dema Stages:

Stage 0 (Latency)

A

Latency
- NO clinical edema–> report heaviness
- (-)Stemmer–bc NO edema!
- Tissue/skin appear NORMAL

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21
Q

Lymph03dema Stages:

Stage 1: **Reversible **

Think “Pitting”
SEE REVERSIBLE—-W/ ELEVATION!! BC GRAVITY!!!

A

Reversible
- Edema present (soft/pitting)
- Edema–> INCs w/ stand/activity BUT reduces w/ elevation (gravity assists)
- (-)Stemmer–bc reversible!

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22
Q

Lymph03dema Stages:

Stage 2: Spontaneously IRreversible

NO longer pitting–> progresses to Brawny (strong guy, hard)

Key words: Hard, Fibrosclerotic, proliferation adipose

A

Spontaneously Irreversible
- Hard swelling; progresses to NONpit BRAWNY edema
- (+)Stemmer, (still neg. in early stage II)
- Tissue appears fibrosclerotic (hard); prolif of adipose

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23
Q

Lymph03dema Stages:

Stage 3: Lymphostatic Elephantiasis

Elephant one

A

Lymphostatic Elephantiasis
- Edema!–SEVERE, Brawny, NONpit
- (+)Stemmer…obvi.
- Skin Changes!–papillomas, deep skinfolds, warty protrusions, hypERkeratosis, mycotic infxs—SEE THESE WORDS==STAGE 3!!!!
- Bacterial/viral infxs common

SKIN CHANGES==STAGE 3!!!

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24
Q

PRACTICE!
Female referred w/ lymphedema. NOTABLE swelling HARD and fibrotic, (+) stemmer, hypERkeratosis (skin changes!!!). Which stage?

A

Stage 3
SKIN CHANGES!!!

0= latency, 1= reversible, 2= spont. irreversible, 3=elephantiasis

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25
Q

How do you remember the Grading scale of edema and Pitting??

Pitting is ONLY Stage 1 and EARLY Stage 2

A

$1= 4 quarters

26
Q

Grading Scale of Edema –$1=4 quarters

1+

A

Mild, barely perceptible (no secs) indent
<.25in pitting

4 quarters!

27
Q

Grading Scale of Edema –$1=4 quarters

2+

A

Moderate, easily ID’d depression; return to norm w/in 15s
.25-.5in

4 quarters!!

28
Q

Grading Scale of Edema –$1=4 quarters

3+

A

Severe, depression takes 15-30s rebound
.5-1in

4 quarters!

29
Q

Grading Scale of Edema –$1=4 quarters

4+

A

VERY severe, depression lasts >30s+
>1in

30
Q

Grading Scale of Edema –$1=4 quarters

4+

A

VERY severe, depression lasts >30s+
>1in

31
Q

Practice!
45yo lymph. L. leg. Early stage II (will see pitting). Pitting scale 3+ (.5-1), 15-30s

A

Severe, 15-30s rebound, .5-1in pitting
Fibrosclerotic tissue

32
Q

Practice!
PT exams 46yo w/ radical mastectomy w/ node removal. INITIAL dev. of lymphedema?

A

Decd flex. of fingers
bc DISTAL extremities swell FIRST!

33
Q

LIPedema
How can you remember this?

A

We have 2 Lips! Upper lip; Lower lip
Lipedema is ALWAYS B/L
2 lips, so 2 limbs! B/L!!!
ALSO
- LIP–> Proximal areas (Butt/Thighs)–> UEs NOT affected

34
Q

LiPedema facts

A
  • B/L, only LEs!!
  • PROXIMAL areas–> butt/thighs, NOT DISTAL, NOT UEs
  • Affects skin elasticity, skin sensitive to pressure/touch—bruise/painful
35
Q

Practice!
49yo pt w/ swollen leg. PT suspects LIPedema. What will NOT be seen?

A

High likelihood of dev. cellulitis
(bc cellulitis seen in stage 3 lymph.

NO CELLULITIS IN LIPEDEMA
NO STEMMER SIGN IN LIPEDEMA BC DISTAL not aff.

36
Q

Lymphedema vs LIPedema

A

NOTE
- Distribution- Lymp Uni or Bilat; Lip is B/L
- Cellulitis common in lymph.
- Stemmer sign- +lymph; -Lip

37
Q

Diff Dx based on picture

A

A: Lymphedema
NOT:
- HF–> will see B/L pitting edema
- LIPedema–> B/L and NEVER distal
- Chronic venous insuff–> will see hemosiderin stain, dark pigmentation

38
Q

Measurements for Edema
3 and WHEN to use/keywords to know

A
  1. Girth measure–> for PROX. EDEMA–use 10cm intervals from landmark
  2. Volumetric–> for DISTAL EDEMA– tank of water
  3. Bioimpedance–> KEY WORD: used for pre/post-SURGERY
39
Q

Dx of Lymph03dema
ONLY ONE TO KNOW!

A

Lymphoscintigraphy: measured during REST and EXERCISE
- ID’s Lymphatic INSUFF

40
Q

LymphangITIS==

A

Inflammation of lymph VESSELS
think “angio” is vessels

41
Q

LymphadenITIS

A

Inflamm of lymph NODES

42
Q

LymphadenoPATHY

A

Enlargement of lymph nodes

43
Q

For NPTE:
If stem asks
PROXIMAL edema measure==

A

GIRTH measure

44
Q

For NPTE
If stem asks
Distal (UE/LE) edema measure

A

Volumetric

45
Q

For NPTE
If stem asks
Pre/Post SURGERY edema measure==

A

BioImpedance

46
Q

For NPTE
IF stem asks
Lymphatic INSUFF==

A

Lymphoscintigraphy

47
Q

Practice!
PT assessing lymph nodes 6mos post-op chemo. When assessing lymph nodes, which presentation LEAST likely req’s referral? Aka what SHOULD lymph nodes feel like?

A

SHOULD BE:
- soft
- free moving
- NON-tender
- NOT easily palpated
- UP to 1cm diameter

48
Q

Palpation of lymph nodes

A

SHOULD BE:
- soft, non-tender, non palpable, up to 1cm
Abnormal: report to physician if abnorm
- tender, hard, immobile
- Metastatic tumor

49
Q

Mgmt of Lymphedema
Main ideas/interventions

A

MAIN goal== MIN. lymphedema OR return to latency stage (stage 0)
- Interstitial press. INCd by EXT forces– MLD or Compression–pushes fluid into bloodstream
- Dynamic press. changes w/in body– Diaphragmatic breathing or mm contracts (pump)
- **MM contracts COMBO’d w/ EXT forces (see above) from bandage or compression EVEN MORE EFFECTIVE in mvmt of fluid

50
Q

Manual Lymphatic Drainage: MLD

KEY THINGS TO REMEMBER!

A
  • ALWAYS LOW stretch (SHORT-stretch)
  • Clear fluid PROX to DIST
  • Direction of massage–> Dist to Prox
51
Q

MLD:
Guidelines

A
  • Proximal congestion in trunk, groin, butt, axilla cleared FIRST to make room for fluid from DIST areas (think traffic jam)
  • The direction of massage is twrds specific lymph nodes–usually involves DIST-> PROX stroking (effleurage)
  • Fluid in involved extremity cleared– FIRST proximal portion THEN distal portion
52
Q

CDT aka
Complete Decongestive Tx
Phase I

Phase II in pics

A
  • MLD (Decongest): Prox to Dist areas (the DIRECTION of stroking is DIST-> PROX (bc want to move fluid back proximal, but start in PROX areas to clear traffic)
  • Exercises–mm pump–Prox–> Distal mm’s
  • Garments– SHORT (LOW) stretch, pressure more distal
53
Q

Compression Therapy
Type of compression depends on….

54
Q

Compression therapy:
Phase 1

what do you HAVE TO REMEMBER?

A

LOW (SHORT) STRETCH BANDAGE!!!
==HIGH WORKING PRESSURE, LOW resting pressure
short stretch meaning it doesnt like to stretch so when you do stretch it the tension is HIGH and will be working HARD (High) when stretched

55
Q

Compression Tx:
Phase 1:

A
  • ONLY LOW (SHORT) stretch== LOW resting pressure (limb @ rest) but HIGH working pressure
  • Day/Night
  • Active reduction phase–> LOW stretch

High (long) stretch– ACE; NOT RECOMMENDED–> mostly sports inj’s

56
Q

Compression Tx for Lymphadema
More on this

A

We want LOW (SHORT) stretch–> doesnt actually stretch much means HIGH working pressure bc you FORCE stretch

57
Q

Practice!
PT examining 46yo pt w/ radical mastectomy (UE). INtervention?

A

Trunk and Axilla (proximal) decongested FIRST f/b arm/ hand

Remember Traffic Jam!!! Clear proximal first (masage dir. opp)

58
Q

MM ex’s for UE lymphedema

A

Remembe Proximal ex’s first!!!

59
Q

Practice!
PT dev. ex program for pt w/ UE Lymph. Which ex do first?

A

CERVICAL rotation!
NOTES:
- Trunk/Spine always FIRST (PROXIMAL!)
- DEEP breathing always always always FIRST BEFORE ANYTHING!!!

60
Q

Last things to rememer

A

NO BP on lymphadema limb
Even if B/L– Usually Asymmetrical (one more swollen vs other)

NPTE Final Frontier (19 decks)

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