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Integumentary > Lymphedema and compression > Flashcards

Lymphedema and compression Flashcards

1
Q

Main functions of lymphatic system:

A

regulate fluid balance

assist with infection control

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2
Q

How much fluid is removed from interstitial space/day?

A

18 liters

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3
Q

Where is fluid removal from?

A

80-90% through veins

remaining 2-4 liters thru lymph system

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4
Q

Estimates of lymphedema type:

A

23–45% of patients after breast cancer
21% of patients after ovarian cancer
28% of patients after endometrial cancer
Up to 70% of patients after prostate cancer

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5
Q

When does lymphedema occur?

A

when the lymphatics cannot remove the remaining interstitial fluid

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6
Q

Chief complaints of lymphedema?

A

Limb heaviness, paresthesias, achiness, skin tightness, poor-fitting clothes, altered cosmesis, decreased ADLs and ROM

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7
Q

Lymphatic anatomy:

A

superficial
deep
perforating

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8
Q

Superficial lymphatics

A

Drains the skin and subcutaneous tissue

Roughly parallels the veins

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9
Q

Deep lymphatics

A

Drains all else (deep tissues and organs)

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10
Q

Lymph

A

fluid made up of water, protein, dead/dying cells/cellular components, fatty acids, foreign material and debris

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11
Q

Lymphangion

A

functional unit of the lymph system

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12
Q

Smaller lymph anatomy:

A 
capillaries
precollectors
collectors
nodes
trunks
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13
Q

Central Lymphatic Flow

A 
Unidirectional valves
Skeletal muscle contraction
Respiratory pump
Aortic pulsations
Lymphangiomotoricity
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14
Q

What is fluid movement between capillaries, interstitium, and lymphatic system governed by?

A

hydrostatic and osmotic pressure

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15
Q

Dynamic insufficiency:

A

If the lymphatic load exceeds the transport capacity of the lymphatic system, edema will occur

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16
Q

Mechanical insufficiency:

A

a decrease in the maximal transport capacity of the lymphatic system, mechanical insufficiency can result

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17
Q

Types of lymphedema

A

primary
secondary
vessel abnormality
age on onset

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18
Q

Primary

A

10% of all cases
Congenital malformation or impairment of lymphatics
LE affected most often

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19
Q

Secondary:

A

Acquired
Disruption of or damage to lymphatics
Much more common

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20
Q

What illnesses is secondary lymphedema common in?

A

Filariasis (parasitic infection)
Cancer treatment
Chronic venous insufficiency

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21
Q

Vessel Abnormality

A

Aplasia
Hypoplasia
Hyperplasia
Lymph node fibrosis

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22
Q

Age at Onset

A

Congenital
Praecox
Tarda

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23
Q

Lipedema

A

Bilateral, symmetrical increase in adipose tissue deposition

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24
Q

What areas does lipedema most commonly affect?

A

Affects abdomen, buttocks, lower extremities but spares the feet

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25
Q

Causes of lipolymphedema;

A

Increased compliance of fat allows interstitial fluid to accumulate

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26
Q

Risk Factors for Lymphedema

A 
Lymph node status
Radiation therapy
Time since surgery
Air travel without compression
Inflammation/Increased Lymphatic Load
Decreased Lymphatic Return
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27
Q

Lymph Node Status

A

Surgical removal increases risk

More removed, the greater the risk

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28
Q

Sentinel lymph node

A

the first lymph node to receive lymph from a tumor

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29
Q

Radiation Therapy

A 
Peri-lymphatic and lymph node fibrosis
Skin damage
Sclerosis/fibrosis
Dermal atrophy
Decreased sweat glands
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30
Q

What percentage of breast cancer patients who had lumpectomy and axillary radiation developed lymphedema?

A

26%

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31
Q

Time Since Surgery

A

Risk increases over time
Possibly due to lymphatic fatigue
Increased Body Mass Index

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32
Q

Air Travel Without Compression

A

Decreased atmospheric pressure on body while flying allows body to swell
May extrapolate to increased risk when going to areas of high elevation
Compression garment offsets this pressure change

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33
Q

Inflammation/Increased Lymphatic Load

A

Inflammation and infection increase lymphatic load
Avoiding strenuous activity of at-risk limb may prevent muscle microtrauma and inflammation – increased fluid that the patient’s lymph system may not be able to accommodate

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34
Q

Decreased Lymphatic Return

A

Constrictive clothing/jewelry
Tourniquets, blood pressure cuffs
Those Prone to Scar Tissue Formation
Trauma from surgical removal of tumor, nodes, and tissue dissection may cause more scar tissue formation in some patients, such as those at risk for keloids

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35
Q

PT Tests and Measures

for Lymphedema

A

Circumferential Measurements
Weight change with compression
Circulation
Sensory Integrity

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36
Q

Gold standard for lymphedema measurements?

A

volumetric displacement

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37
Q

Why is volumetric displacement rarely used?

A

increased time, infection

risk, equipment needs

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38
Q

Circumferential Measurements

A

Reliable
Can use software programs to convert to volume
Can measure limb every 3, 4, 8, or 12 cm
Include landmarks needed for garments

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39
Q

How can software programs be used to convert to volume?

A

Compare side-to-side
Compare changes over course of treatment
Compare over time

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40
Q

Pulses

A

Palpation

Doppler if needed

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41
Q

Other circulation methods to measure for lymphedema?

A

Capillary refill
Ankle-Brachial Index or Toe-Brachial Index on patients with lower extremity lymphedema
Screen patients with lower extremity lymphedema for DVT

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42
Q

Sensory Integrity

A

Perform monofilament testing on all patients with lymphedema

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43
Q

What can nerve entrapments be caused by?

A

tissue distention, edema, and inflammation

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44
Q

Patients at risk for neuropathy

A

Those with diabetes

Those who received chemotherapy

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45
Q

Stage 0

A

latent
No edema present
Reduced transport capacity of the lymphatic system
Most commonly due to surgery or radiation

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46
Q

Stage 1

A

Reversible
Edema that pits when digital pressure is applied
Greatly or completely reduces with elevation
No secondary skin changes

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47
Q

Stage 2

A

Spontaneously Irreversible
Does not pit when digital pressure is applied
Does not reduce substantially with elevation
Skin becomes fibrotic or brawny
May have frequent skin infections

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48
Q

Stage 3

A

Lymphostatic Elephantiasis
Extreme increase in limb volume
Deep skin folds and papillomas present
Frequent skin infections

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49
Q

Mild lymphedema

A

<3 cm interlimb difference

<20% limb volume increase

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50
Q

Moderate lymphedema

A

3–5 cm interlimb difference

20–40% limb volume increase

51
Q

Severe lymphedema

A

> 5 cm interlimb difference

>40% limb volume increase

52
Q

5PT Method

A 
Pain
Position
Presentation
Periwound
Pulses
Temperature
53
Q

Pain

A 
Deep ache or pressure
stretch pain 
neuropathic pain
pain from infection or inflammation
discomfort, heaviness
If patient complains of pain rather than the above sensations, further evaluation or referral is warranted
54
Q

Position

A

Distal to area of lymphatic obstruction or damage
Must know:
Normal anatomy and drainage patterns
Surgery/procedures in past medical history

55
Q

Presentation

A

lymphorrhea
serous drainage
Drainage can be significant, especially in lower extremity
If infected, drainage may be purulent, seropurulent, and/or copious
Slough-covered wound common

56
Q

Periwound and Structural Changes

A 
pitting
fibrotic
peau d'orange
Stemmer's sign
papillomatosis
fungal infection (scaling, thickened nails)
Hemosideran
deep skin folds
hair loss
Lichenification
Lymphorrhea
Dermatitis
Ulceration
Xerosis
57
Q

Peau D’Orange

A

a dimpling of the skin that gives it the appearance of the skin of an orange. Often due to lymphatic obstruction

58
Q

Pulses

A

normal

59
Q

Temperature

A 
Normal
May be warm to touch due to: 
Edema
Inflammation
Infection
60
Q

Prognosis for mild lymphedema

A

will require 5–10 visits

61
Q

Prognosis for moderate lymphedema

A

will require 14–24 visits

62
Q

Prognosis expectations:

A

Earlier access means faster recovery
Can expect 22–73% volume  in 6–36 visits
Lipolymphedema and stage IV cancers make least progress

63
Q

Proactive education program

A

For at-risk patients
For providers who deal with at-risk patients
For cancer survivor groups

64
Q

Do list:

A

protect from injury, skin checks, how to treat open areas, ideal weight, exercise, garment wear/care

65
Q

Don’t list

A

injections/BP/piercings/tattoos in affected area, hot tubs/saunas, walking barefoot

66
Q

Precautions

A

Rule out cancer recurrence as cause of lymphedema
Spontaneous lymphedema without prior history of lymphatic trauma should be screened by MD
Screen patients with lower extremity lymphedema
Arterial insufficiency
Deep vein thrombosis

67
Q

Request for Further Medical Testing

A

Wound culture and sensitivity if signs and symptoms of infection
Rule out recurrence
If cannot perform an ABI

68
Q

Skin Care

A

Keep skin clean and dry
Avoid perfumes, high-alkaline soaps
Use low pH moisturizers
If open wound, wash with soap and water, apply topical antimicrobial, cover

69
Q

More skin care:

A 
Protect surrounding skin
Skin sealant/moisture barrier
Lotion to intact skin
Absorptive dressing
Compression
Educate patient/caregivers
70
Q

Therapeutic Exercise

A 
Patient positioning
Active range of motion
Flexibility exercise
Anaerobic exercise
Aerobic exercise
Breathing exercise
71
Q

Manual Therapy

A

No method is superior but including manual therapy leads to better results
Advanced training or certification is recommended

72
Q

Manual therapy techniques:

A

Manual lymphatic drainage
Simple lymph drainage
Lymphatic massage

73
Q

Benefits of Manual Therapy

A 
Increases lymph formation
Propels lymph proximally
Increases lymph angiomotoricity
Reroutes stagnated lymph
Encourages development of collaterals
Reduces sympathetic and increases parasympathetic responses
Decreases pain/promotes relaxation
Decreases fibrosis
74
Q

Precautions/Contraindications

for Manual Rx

A 
DVT
Active infection
open wound
metastatic disease
CHF
Asthma
Abdominal inflammatory condition/pregnant
75
Q

Open wound precautions:

A

treat intact skin only

76
Q

Metastatic disease precautions:

A

can use palliatively

77
Q

CHF precautions:

A

start slowly, progress slowly

78
Q

Asthma precautions:

A

start slowly, monitor asthma

79
Q

Abdominal inflammatory conditions/pregnant precautions:

A

do not perform deep abdominal treatment

80
Q

Manual therapy movement:

A

Clear (empty/drain) proximally before moving incrementally more distal
Venous angles where lymphatics empty into venous system
Trunk
Affected extremity
Rework often to reclear

81
Q

Compression Therapy

A 
Reduces ultrafiltration
Enhances venous return
Improves effectiveness of muscle pump
Increases angiomotoricity
May reduce fibrosis
82
Q

Multilayer Compression Bandaging

A 
Skin care: wash, dry, apply lotion
Wound care as needed including absorptive dressing
Cotton liner
Digit bandage
Padding: cotton, foam, custom-made
Short-stretch compression bandages
83
Q

Precautions/Contraindications

for Compression Bandaging

A

Arterial insufficieny
Radiation damage with intact skin
DVT
CHF: start slowly, progress slowly
Open wound: proper infection control, appropriate dressing/skin care
Infection
Patients who are weak, immobile, insensate

84
Q

Mild lymphedema

Prophylactic UE

A

10–21 mm Hg

Light

85
Q

Moderate to severe UE lymphedema

Mild LE lymphedema

A

15–32 mm Hg

Medium

86
Q

Moderate to severe LE lymphedema

A

30–40 mm Hg

Strong

87
Q

Stage 3 LE lymphedema

A

<40 mm Hg

Very strong

88
Q

Compression Pumps

A

Single or multichamber
Ideally also compresses trunk quadrant
Poor patient adherence
Rarely good intervention strategy

89
Q

What does a compression pump do?

A

Remove fluid from the area, but not protein
Once stopped, protein draws fluid back
Residual protein leads to fibrosis

90
Q

Two phases of intervention

A

intensive

self-management

91
Q

Intensive

A

High frequency of visits over short term

Learn self-care

92
Q

Self-management

A

Ongoing

Maintenance of edema reduction

93
Q

Medical Testing

A

Rule out serious medical conditions
Cancer/recurrence of cancer
DVT
CHF, etc.

94
Q

Medical Interventions

A

Manage risk factors

Pharmacological

95
Q

Surgical Interventions

A

Debridement
Microsurgical procedures
Debulking surgeries

96
Q

Effects of Compression

A 
Enhances calf muscle pump
Improves venous return
Decreases peripheral edema
Reduces venous distension
Increases tissue oxygenation
Softens lipodermatosclerosis
Protects limb from trauma
Limits need for prolonged elevation/bed rest
97
Q

Compression Parameters

A

30–40 mm Hg at ankle
10 mm Hg at infrapatellar notch
If severe VI, can increase to 40–50 mm Hg
If mild AI, can decrease to 20–30 mm Hg

98
Q

Contraindications to Compression

A 
ABI < 0.7
Acute infection
Pulmonary edema
Uncontrolled or severe congestive heart failure
Active DVT
Claustrophobia (relative)
99
Q

Types of Compression

A 
Paste bandage
Short-stretch compression bandage
Multilayer compression bandage system
CircAid
Tubular bandages
Compression garments
Vasopneumatic compression devices
100
Q

Paste Bandages

A 
A nonelastic compression 
Gauze, in a cloth roll bandage that is impregnated with zinc oxide, calamine, glycerin, and gelatin
Hardens into a semi-rigid support
Stays on for up to 1 week
Used on ambulatory patients
101
Q

Paste bandage disadvantage:

A

odor
pruritus
Inability to shower or get the dressing wet
Should not be used in areas of high humidity
Unable to accommodate changes in limb size

102
Q

Short-Stretch Compression Bandages

A

Low resting pressure and little distensibility
Ambulatory and nonambulatory patients
Amount of compression determined by Laplace’s law
Need enough to reduce edema without causing ischemia

103
Q

Short-Stretch Compression Bandages disadvantages

A

Prone to slippage, causing frequent wrapping

Patients must be trained in correct technique

104
Q

Inner layer

A

Absorbs excess wound drainage

Provides padding

105
Q

Middle layer

A

short stretch

106
Q

Outer layer

A

1–2 layers are long stretch providing increased compression

107
Q

Multi-layer Bandage

A

Mimics high working pressure (during standing up to almost 50mmHg) and low resting pressure for tolerance at night
Used mostly in the presence of ulcerations

108
Q

Velcro Compression Garment

A

Removable, semi-rigid orthotic compression device
Consists of rows of nonelastic Velcro straps that provide sustained compression
Easy to apply

109
Q

Velcro Compression Garment Disadvantages:

A

High one-time cost

Need for patient adherence for daily wear

110
Q

Tubular Bandages

A

Off-the-shelf sleeves
Available in several widths and compressions
Allow for graduated compression

111
Q

Tubular Bandages Disadvantages:

A

Generic shapes and sizes do not accommodate all patients

Bandages lose shape and compression in a short time

112
Q

Long Stretch Bandage

A

Provide mild compression (18-24 mm hg)
Must be applied properly to be effective
Can decrease dependent edema
Elastic-extend beyond 100%

113
Q

Compression Stockings

A

Gradient with pressure greatest at the ankle and decreasing superiorly
Flat knit vs. circular
Over the counter vs. custom
8-50mmHg

114
Q

Compression Hose light support

A

8-14mmHg- edema prevention for extensive sitting and standing with minimal activity

115
Q

Compression Hose antiembolism stockings:

A

16-18mmHg- Deep vein prophylaxis, non- ambulatory patients with edema, includes TED hose

116
Q

Compression Hose low compression

A

18-24mm Hg - Non-ambulatory patients with edema failing 16-18mmHg stockings, includes elastic bandages and paste bandages for clients with dependent edema

117
Q

Compression Hose low to moderate

A

25-35 mmHg- edema secondary to venous insufficiency, for clients able to participate in exercise, includes 4-layer wraps

118
Q

Compression Hose moderate

A

30-40mmHg- Edema with or without ulceration, edema that persists despite lower level compression options, includes four layer bandage

119
Q

Compression Hose high

A

40-50mmHg-edema secondary to lymphedema

120
Q

Compression Class 0

A

< 20mmHg

non ambulatory patients

121
Q

Compression Class 1

A

20-30 mmHg
mild venous insufficiency
VI with mild AI

122
Q

Compression Class 2

A

30-40 mmHg

moderate VI

123
Q

Compression Class 3

A

40-50 mmHg

severe VI

124
Q

Compression Class 4

A

> 50 mmHg

severe VI

Integumentary (18 decks)

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