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Other disorders > Lymphedema > Flashcards

Lymphedema Flashcards

1
Q

Lymphatic system

A
  • parallel to the venous system
  • present in all parts of the body except the CNS and the cornea
  • the body has 600-700 lymph nodes with the greatest groupings in the head and neck, axilla, groin, and intestines
  • in a normal state the lymphatic system transports lymphatic fluid back to the venous circulation
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2
Q

lymphatic pathway

A
  • lymphatic system capillaries located close to blood capillaries and are responsible for pulling fluid into the lymphatic circulation
  • once in lymphatic vessels, fluid transported from lymph nodes to lymphatic trunks to venous angles
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3
Q

Lymphedema

A

• an excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces. It occurs when lymph volume exceeds the capacity of the lymph transport system

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4
Q

Lymphatic fluid

A

water, waste, fat, and protein

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5
Q

Lymphatic load

A

amount of fluid transported

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6
Q

transport capacity

A

amount of fluid the lymphatic system can transport
•when balance is interrupted due to increased lymphatic load or a decreased transport capacity lymphedema may develop
•

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7
Q

quadrants

A

When a quadrant’s lymph structures are affected the entire quadrant which empties into those structures can demonstrate lymphedema

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8
Q

transport capacity in primary lymphedema

A

Transport capacity is affected when structures of the lymphatic system are impaired either by problems in the anatomical lymphatic structures= Primary Lymphedema

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9
Q

transport capacity in secondary lymphedema

A

due to injury to lymphatic structures via surgery, radiation, trauma, or infection= Secondary Lymphedema.

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10
Q

Primary lymphedema

A
  • Less common, the result of insufficient development (dysplasia) and congenital malformation of the lymphatic system.
  • Affects more females than males.
  • Affects lower extremities greater than upper extremities
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11
Q

types of primary lymphedema

A

Identified by age presentation:
•Congenital (Milroy’s disease) presents at birth
•Praecox (early) develops before 35 y/o
•Tarda: develops after 35 y/o

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12
Q

Secondary Lymphedema

A

•Most common form of lymphedema caused by damage to lymphatic structures through:

  • Surgical dissection of lymph nodes for cancer- i.e axillary for breast cancer, pelvic or inguinal nodes for pelvic (prostate) or abdominal cancers
  • Systemic infection or Local trauma
  • Obstruction, fibrosis-i.e from radiation
  • Combined venous-lymphatic dysfunction
  • Filariasis parasites
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13
Q

Clinical manifestations of lymphedema

A
  • As develops most often apparent in distal extremities especially over dorsum of hand or foot and may manifest more centrally in the axilla, groin , trunk and genitals.
  • Described by severity of changes that occurs in skin and subcutaneous tissues and progresses from
  • Pitting-> Non- pitting (i.e brawny) weeping
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14
Q

types of edema

A
  • Pitting
  • brawny
  • weeping
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15
Q

Pitting edema

A

indentation of the skin that persists for several seconds after pressure is removed. No fibrotic changes.

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16
Q

Brawny edema

A

edematous area feels hard with palpation. Progressive fibrotic changes.

17
Q

Weeping edema

A

most severe- fluid leaks from cuts and sores. Wound healing impaired

18
Q

Degrees of pitting edema

A

1+: indentation barely detectable
2+: slight indentation when skin is depressed- returns to normal in 15 seconds
3+: deeper indentation when pressed- returns to normal within 30 seconds
4+: indentation lasts for more than 30 seconds

19
Q

when skin is interrupted…

A

When skin is interrupted , it is common to see a seeping of clear, yellow tinged fluid that is slightly thicker than vascular fluid. The increased viscosity is due to protein in the fluid. Severe condition if leaking through pores of skin

20
Q

Sensory and ROM disturbances with lymphedema

A

Sensory disturbances- paresthesia, aching, heaviness may be felt. Finger coordination may be impaitred
ROM of fingers and wrist or toes and ankle may be decreased

21
Q

Lymphedema and infection

A

wound healing is delayed/ frequent infections and cellulitis (medical emergency) may occur

22
Q

Stage 0

A

Latency stage:
• essentially asymptomatic, occasional reports of heaviness
•has reduced transport capacity (i.e. loss of lymph nodes or fibrosis of lymph nodes- but body is still able to accomadate the lymphatic load so there is no swelling.
• this stage may present with the greatest possibility for reducing the onset of lymphedema K box 1024

23
Q

Stage I

A

Reversible pitting edema:
• elevation reduces swelling, may be normal in morning
• no tissue fibrosis
•swelling is soft or pitting

24
Q

Stage II

A

Spontaneously Irreversible:
•fibrosis of soft tissue, brawny, hard, swelling (non pitting)
• positive stemmer sign
•frequent infections (i.e. cellulitis) may occur

25
Q

Stage III

A

Lymphastatic Elephantiasis:
•positive stemmer sign
• significant increase in limb volume
•typical changes noted- hyperkeratosis, papillomas, deep skin folds
•bacterial and fungal infections of the skin and nails are more common

26
Q

Stemmer sign

A
  • (+) in stage I and II
  • a positive Stemmer sign is an indication of Stage I or II lymphedema
  • considered positive if the skin on the dorsal surface of the fingers or toes cannot be pinched or is difficult to pinch compared to the uninvolved limb
27
Q

Other tests and measures for lymphedema

A

•History and systems review
Exam of skin integrity- amount of edema, type of edema, papillomas, signs of infection- cellulitis, Stemmer sign, condition of nails, presence of fungus
•Girth measurements-specific intervals/ landmarks, anatomical landmarks, specialized measuring boards
•Volumetric measurements (more cumbersome, less practical- esp. for LE)
•Bioimpedence measurements- the higher the resistance to flow the more extracellular fluid is present
•ROM measurements- esp. hands, wrist, feet/ ankle, knee/ elbow, shld/ hip/ trunk- esp. as it relates to functional loss
•Fine and gross coordination
Balance/ Bed mobility/ Transfers/ Gait/ Hygiene function

28
Q

Lymphedema management phase I

A
  • manual lymphatic drainage (MLD) by clinician
  • multiple layer compression bandaging (worn until next session)
  • skin and nail care
  • exercise
29
Q

Lymphedema management phase II

A
  • self MLD by patient
  • compression therapy- compression garment during day and multiple layer bandaging at night
  • skin and nail care
  • exercise
30
Q

Lymphedema management: pressure changes, diaphragmatic breathing, and muscle contractions

A
  • Dynamic pressure changes within the body can assist with lymphatic flow
  • pressure changes can be in the form of diaphragmatic breathing producing intrathoracic pressure changes and causing an increased uptake of lymph fluid in the lymphatic trunks and ducts (especially important for patients with LE lymphedema
  • Active muscular contractions change pressure in a localized area which can be made even more effective combined with external forces from a bandage or compression garment
31
Q

Possible contraindications to MLD and compression

A
  • CHF
  • some pulmonary disorders
  • renal failure/disease
  • active infection
  • DVT
32
Q

Sequence of exercises

A

•Diaphragmatic breathing is performed prior to lymphatic drainage exercises
• Exercise in particular sequence to enhance lymph flow:
- central and proximal lymph vessels i.e. abdominal, inguinal, and cervical nodes are cleared first with trunk, pelvic, hip, and cervical exercises
- then exercise proceeds distally from shoulders to fingers or hips to toes
• compression garments or bandages should be worn throughout

33
Q

Lymphedema education

A

Patients should position the affected extremities to avoid constriction or the pooling of blood and fluids, Advise them to:

  • elevate the arm or leg above heart level
  • avoid rapid movements that could cause centrifugal pooling of fluid in hands or legs
  • avoid heat to limbs (heat can increase blood flow) avoid hot baths and saunas
  • avoid strain or constrictive pressure that may obstruct lymph flow (but do not avoid using the affected or at-risk limb altogether)
  • avoid tight fitting jewlery and clothing, elastic bandages, clothing with constrictive bands, and BP monitoring equipment on the lymphedemic arm
  • avoid carrying a purse or heavy objects on the affected arm
  • sit smart: do not cross legs while sitting or sit in one position for more than 30 minutes
34
Q

Venous circulation…

A

empties into the vena cava, which is why lymphedema massage is contraindicated in patients with CHF

35
Q

MLD

A

work proximal to distal as opposed to retrograde message for regular edema which would be distal to proximal

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