Lymph Edema Tutorial (1)

8/8/2019 Lymph Edema Tutorial (1)

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LymphedemaLymphedemaEmily Richter, RN, BSN, OCNEmily Richter, RN, BSN, OCN

Alverno CollegeAlverno CollegeSpring 2007Spring 2007

Click on arrow for next slide


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Directions for TutorialDirections for Tutorial

Use the arrows at the bottom of the page toUse the arrows at the bottom of the page tomove about the tutorial.move about the tutorial.

This arrow moves you forwardThis arrow moves you forward

This arrow takes you back one pageThis arrow takes you back one page

This button will take you back to the main menuThis button will take you back to the main menu


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ObjectivesObjectives

Understand/describe the normal structure and functionUnderstand/describe the normal structure and functionof the lymphatic system.of the lymphatic system.

Identify risk factors affecting the normal drainage of theIdentify risk factors affecting the normal drainage of thelymphatic system.lymphatic system.

Discuss diseases or procedures that could predispose aDiscuss diseases or procedures that could predispose apatient to lymphedema.patient to lymphedema.

Explain assessment of a patient with lymphedema.Explain assessment of a patient with lymphedema.

Describe nursing interventions to promote lymphaticDescribe nursing interventions to promote lymphaticdrainage for a patient with lymphedema.drainage for a patient with lymphedema.

Participate in a case studyParticipate in a case study


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Table of ContentsTable of Contents

Choose a topic listed below to go to that sectionChoose a topic listed below to go to that section

of the tutorial.of the tutorial.

1. Pathophysiology

2. Risk Factors

4. Prevention and

Treatment

5. Nursing Diagnoses

6. Case Study

3. Diagnosis


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What is lymphedema?What is lymphedema?

Lymphedema is anLymphedema is anabnormalabnormal

accumulation ofaccumulation of

highhigh--proteinproteinconcentrated fluid,concentrated fluid,

usually in the armsusually in the arms

and legs.and legs. Dell & Doll, 2006Dell & Doll, 2006

Image reproduced with permission

from vascularsociety.org


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TheLymphaticsTheLymphatics

The lymphatic systemThe lymphatic systemfilters and collectsfilters and collectslymph and largelymph and large

molecules in themolecules in theinterstitialinterstitial space thatspace thatcome from thecome from theintravascular space.intravascular space.

Golshan & Smith, 2006Golshan & Smith, 2006

Used with permission from lymphacare.com


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Normally, the heart pumpsso strongly that itNormally, the heart pumpsso strongly that it

causes 20causes 20--30 liters of plasma per day to leak30 liters of plasma per day to leakfrom the capillaries. This is thefrom the capillaries. This is the interstitialinterstitialfluid,fluid,

which the lymphatic system drains, filters, andwhich the lymphatic system drains, filters, and

returns to the heart.returns to the heart. Nazarko, 2006Nazarko, 2006


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ThisThisinterstitialinterstitialfluid contains proteins, lipids, water,fluid contains proteins, lipids, water,

and products from cellular breakdown.and products from cellular breakdown. Golshan & Smith, 2006Golshan & Smith, 2006

Lymphatic vessels are similar to veins, but withLymphatic vessels are similar to veins, but withthinner walls to allow larger proteins to permeatethinner walls to allow larger proteins to permeate

through.through. Holcomb, 2006Holcomb, 2006

National Cancer Institute, 2006National Cancer Institute, 2006


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Lymph vessels usually do not have a largeLymph vessels usually do not have a large basementbasementmembranemembrane, which allows large molecules to enter, which allows large molecules to enter

that cannot be reabsorbed readily by the venousthat cannot be reabsorbed readily by the venoussystem.system. Golshan and Smith, 2006Golshan and Smith, 2006

Used with permission by www.med-ars.it


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Once thisOnce thisinterstitialinterstitialfluid isfluid isabsorbed, it moves throughabsorbed, it moves through

the lymphatic vessels, and isthe lymphatic vessels, and isconsidered lymph fluid.considered lymph fluid.

As lymph fluid movesAs lymph fluid movesthrough the lymphaticthrough the lymphatic

system, it passes throughsystem, it passes throughlymph nodes.lymph nodes. Lymph nodesLymph nodesfilter harmful substancesfilter harmful substancesand contain lymphocytesand contain lymphocytes

that activate the immunethat activate the immunesystem.system. National Cancer Institute,National Cancer Institute,

20062006Used with permission from

Lymphnotes.com


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The lymph system carries theThe lymph system carries the lymphocyteslymphocytes

throughout the body to respond to antigens andthroughout the body to respond to antigens andcommunicate responses to other parts of thecommunicate responses to other parts of thebody.body.

Lacovara & Yoder, 2006Lacovara & Yoder, 2006


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Lymph then travels through multiple lymphatic channelsLymph then travels through multiple lymphatic channelsand nodes before returning to the venoussystem by theand nodes before returning to the venoussystem by the

thoracic duct.thoracic duct. Golshan and Smith, 2006Golshan and Smith, 2006

Used with permission by med-ars.it


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Under normalUnder normal

conditions, the entry ofconditions, the entry of

fluid and other materialsfluid and other materialsinto the interstitial spaceinto the interstitial space

is balanced by outflowis balanced by outflow

of the lymphatic fluidof the lymphatic fluid

from the limb, whichfrom the limb, whichmaintainsstandardmaintainsstandard

volume.volume. Golshan and Smith,Golshan and Smith,

20062006

Used with permission

from www.med-ars.it


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Lymphedema occurs when there is an interruption orLymphedema occurs when there is an interruption orobstruction of the lymphatic system that causes anobstruction of the lymphatic system that causes an

accumulation of fluid in the limb.accumulation of fluid in the limb. Golshan & Smith, 2006Golshan & Smith, 2006

Used with

permission

from

lymphacare

.com


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A healthy adult has approximately 600A healthy adult has approximately 600--700 lymph700 lymph

nodes.nodes. Lacovara & Yoder, 2006Lacovara & Yoder, 2006

The main areas are:The main areas are:

SupraclavicularSupraclavicular Retroperitoneal (deep abdomen and pelvis)Retroperitoneal (deep abdomen and pelvis)

TracheaTrachea

Thoracic (adjacent to the lung)Thoracic (adjacent to the lung) Thiadens, 2005Thiadens, 2005


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Abdominal (near the intestine)Abdominal (near the intestine)

AxillaAxillaThe pelvic areaThe pelvic area

InguinalInguinal

Also found in tonsils,Also found in tonsils,spleen, intestinal wall,spleen, intestinal wall,

and bone marrow.and bone marrow.

Thiadens, 2005Thiadens, 2005


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Identify Major Lymph NodesIdentify Major Lymph NodesClickon thebodyClickon thebody

Used with permission from cancerbackup.org

Spleen

Inguinal Nodes

Cervical Nodes

Axillary Nodes


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Reviewofthe FlowReviewofthe FlowClickon the screenClickon the screen

Interstitial fluid has

diffused from bloodcapillaries

The lymph capillariesabsorb this interstitial

fluid

The capillaries join

to form vessels thatcarry the lymph fluid

back to the heart.

On the trip back, thelymph fluid passes

through lymph nodes,

where it is cleaned and

filtered

The lymph fluid then

enters either the thoracicduct or right lymphatic duct

The fluid is then enters the

subclavian veins and is returned

to the circulatorysystem.

Thoracic Duct

www.lymphacare.com

Mader, 1994


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Why is thelymphatic system soWhy is thelymphatic system so

important?important?(Clickon allcorrectanswers)(Clickon allcorrectanswers)

A. The lymph system collects excess tissue fluid.A. The lymph system collects excess tissue fluid.

B. It plays a major role in the bodys defenseB. It plays a major role in the bodys defense

against disease.against disease.

C. It circulates blood throughout the bodyC. It circulates blood throughout the body


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Right!Right!

The lymph system absorbs interstitialThe lymph system absorbs interstitialfluid and returns it back to the bloodfluid and returns it back to the bloodcirculation.circulation.

Click here to return to questionClick here to return to question


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Correct!Correct!

The lymph system circulates lymphocytes, suchThe lymph system circulates lymphocytes, such

as T Cells, B Cells, and NK Cells.as T Cells, B Cells, and NK Cells.



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IncorrectIncorrect

This is a different system. the lymphaticThis is a different system. the lymphaticsystem contain

sfluid, not blood.

system contain

sfluid, not blood.



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RiskFactor: SurgeryRiskFactor: SurgeryAnysurgery that dissects or removes lymph nodesAnysurgery that dissects or removes lymph nodes

increases the risk of lymphedema by impairing theincreases the risk of lymphedema by impairing thelymph flow.lymph flow.

Marrs, 2007; Lacovara & Yoder, 2006Marrs, 2007; Lacovara & Yoder, 2006

Common cancers that may require surgicalCommon cancers that may require surgicalalterations of the lymph nodes include breastalterations of the lymph nodes include breastcancer, melanoma, gynecological cancers, headcancer, melanoma, gynecological cancers, headand neck, prostate, testicular, bladder, or colonand neck, prostate, testicular, bladder, or coloncancer.cancer.



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RiskFactor: ObstructionRiskFactor: Obstruction

Tumors themselves may cause lymphedema byTumors themselves may cause lymphedema by

obstructing the lymphatic vessels.obstructing the lymphatic vessels. Dell & Doll, 2006Dell & Doll, 2006

This is can be seen with cervical cancer, prostateThis is can be seen with cervical cancer, prostate

cancer, or head and neck cancer.cancer, or head and neck cancer. Nazarko, 2006; Romero, 2007.Nazarko, 2006; Romero, 2007.


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RiskFactor: RadiationRiskFactor: Radiation

Radiation therapy to theRadiation therapy to theaxillary or groin regionaxillary or groin region

around the lymph node canaround the lymph node can

cause fibrosis and scarring ofcause fibrosis and scarring ofthe tissue and thereforethe tissue and thereforecause lymphedema to occur.cause lymphedema to occur.

Golshan & Smith, 2006Golshan & Smith, 2006


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RiskFactor: LymphedemaRiskFactor: Lymphedema

and Breast Cancerand Breast Cancer It is estimated that 15It is estimated that 15--20% of patients with20% of patients with

breast cancer will experience lymphedema.breast cancer will experience lymphedema. Lacova & Yoder, 2006Lacova & Yoder, 2006

The tumor bed in the breast may drain into theThe tumor bed in the breast may drain into thelymphatics.lymphatics.

Dow, 2002Dow, 2002


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The sentinel lymph node is the first lymph nodeThe sentinel lymph node is the first lymph node

draining from this tumor bed.draining from this tumor bed. Dow, 2002Dow, 2002

Used with permission from www.med-ars.it

Tumor Sentinel Node


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A technique called Sentinel Node Biopsy can beA technique called Sentinel Node Biopsy can be

performed, which the surgeon finds and removesperformed, which the surgeon finds and removesthis first node and sends it for a pathologicthis first node and sends it for a pathologic

examination.examination. Dell, 2005Dell, 2005

If the sentinel node is benign, no further lymphIf the sentinel node is benign, no further lymphnode removal is needed.node removal is needed.

Thaidens, 2005Thaidens, 2005


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However if theHowever if the

sentinel node i

s

sentinel node i

spositive, the axillarypositive, the axillary

nodes may need to benodes may need to be

removed, whichremoved, which

increases the chancesincreases the chancesof lymphedema byof lymphedema by

3030--60%.60%. Golshan and Smith, 2006Golshan and Smith, 2006

Used with permission from

Bocaradiology.org


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Other Risks: Infection andInjuryOther Risks: Infection andInjuryThingssuch as infections, bug bites, and beeThingssuch as infections, bug bites, and bee

stings may lead to lymphedema in a highstings may lead to lymphedema in a high--riskriskpatient.patient.

Trauma to the extremity at risk may also causeTrauma to the extremity at risk may also causelymphedema.lymphedema.The rationale is lymphatic flow increases to theThe rationale is lymphatic flow increases to the

affected site, however there is an obstruction oraffected site, however there is an obstruction or

defect in the lymphatic system, causing lymph fluid todefect in the lymphatic system, causing lymph fluid toleak.leak. Dell & Doll, 2006Dell & Doll, 2006


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Other PossibleRisks:Other PossibleRisks:

Other causes that may lead to lymphedemaOther causes that may lead to lymphedema

include:include:

Scarring from a vesicantScarring from a vesicant extravasationextravasation

Local burnsLocal burns

Lymph node metastasisLymph node metastasis Itano & Taoka, 2005Itano & Taoka, 2005


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Review: Whatcancers can beReview: Whatcancers can be

associatedwithlymphedema?associatedwithlymphedema?

Malignant MelanomaMalignant Melanoma

GynecologicalGynecological

CancersCancers Head and NeckHead and Neck

ColonColon

Prostate/BladderProstate/Bladder

SarcomaSarcoma

Click on all of the

correct answers


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Correct! Malignant Melanoma can lead to lymphedema.Correct! Malignant Melanoma can lead to lymphedema.HereHeres how:s how:

Malignant melanoma can metastasize to regional lymphMalignant melanoma can metastasize to regional lymphnodes. Treatment for malignant melanoma maynodes. Treatment for malignant melanoma mayinvolve surgical resection; depending on location andinvolve surgical resection; depending on location andextent of disease, the lymph nodes may need to beextent of disease, the lymph nodes may need to be

removed.removed. Itano & Taoka, 2005Itano & Taoka, 2005

Possible risk areas:

Axillary Nodes

Inguinal Nodes

www.

cancebackup.org

Click here

to return

to question


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Right! HereRight! Heres how:s how:

When you think of gynecologic cancers (ovarian, uterine,When you think of gynecologic cancers (ovarian, uterine,cervical), think location. Surgical removal of the inguinalcervical), think location. Surgical removal of the inguinallymph nodes puts the patient at risk for lower extremitylymph nodes puts the patient at risk for lower extremitylymphedema.lymphedema.

Inguinal Nodes

www.

cancebackup.org

Click HERE to returnto question


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Correct! Head and Neck cancerCorrect! Head and Neck cancer

can cause lymphedema.can cause lymphedema.HereHeres how:s how:

Squamous cell carcinoma occurring in the head andSquamous cell carcinoma occurring in the head andneck may obstruct lymph nodes or require removalneck may obstruct lymph nodes or require removal

of near by nodes.of near by nodes. A common treatment of head and neck cancer alsoA common treatment of head and neck cancer also

includes radiation.includes radiation. Romero, 2007Romero, 2007

Click HERE to return to questionClick HERE to return to question


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Right! HereRight! Heres how colon cancer can lead tos how colon cancer can lead tolymphedema:lymphedema:

Tumors can invade beyond the submucosal layerTumors can invade beyond the submucosal layerand have direct access to the lymphatic system.and have direct access to the lymphatic system.

Itano & Taoka, 2005Itano & Taoka, 2005

Treatment for colon cancer includessurgery andTreatment for colon cancer includessurgery andradiation, which may damage regional lymphradiation, which may damage regional lymphnodes.nodes.



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Good! LetGood! Lets look at how prostate ands look at how prostate andbladder cancer can lead to lymphedema:bladder cancer can lead to lymphedema:

In advanced bladder cancer, a cystectomyIn advanced bladder cancer, a cystectomymay be performed, removing the bladder,may be performed, removing the bladder,prostate (men) and hysterectomy (women).prostate (men) and hysterectomy (women).


Radiation is also a method of treatment for advancedRadiation is also a method of treatment for advancedstages, putting regional lymph nodes at risk.stages, putting regional lymph nodes at risk.

This patient would be at risk for lower extremityThis patient would be at risk for lower extremitylymphedema.lymphedema.



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Yes! Sarcoma can lead toYes! Sarcoma can lead to

lymphedema. Herelymphedema. Heres how:s how:

The goal of treatment forThe goal of treatment forsarcoma issurgical removal.sarcoma issurgical removal.


Depending on location, lymph nodes may be damaged ofDepending on location, lymph nodes may be damaged ofremovedremoved

Radiation may be used to reduce tumor size. This alsoRadiation may be used to reduce tumor size. This also

puts lymph nodes at risk for fibrosis.puts lymph nodes at risk for fibrosis.



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Diagnosing LymphedemaDiagnosing Lymphedema Painlessswelling of the arms or legs, which mayPainlessswelling of the arms or legs, which may

get worse during the day and better at night.get worse during the day and better at night.

Warmth or achiness in the extremity.Warmth or achiness in the extremity.

A feeling of tightness, heaviness, tingling,A feeling of tightness, heaviness, tingling,numbness, or weakness in the affected extremity.numbness, or weakness in the affected extremity.

Redness of the affected extremity.Redness of the affected extremity.

Bracelets, rings, or shoes may become tight.Bracelets, rings, or shoes may become tight. Lacovara & Yoder, 2006Lacovara & Yoder, 2006


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Diagnosis, ContinuedDiagnosis, Continued

A 2 cm difference between affected extremityA 2 cm difference between affected extremityand nonand non--affected extremity is a generalaffected extremity is a generalclassification.classification.

Bicego, et al, 2006Bicego, et al, 2006

Tends to occur distal to proximalTends to occur distal to proximal

Increased pigmentation/superficial veinsIncreased pigmentation/superficial veins

Secondary cellulitisSecondary cellulitis Itano & Taoka, 2005Itano & Taoka, 2005


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InfectionInfection

Infection may be common in lymphedema;Infection may be common in lymphedema;

pooling of proteinpooling of protein--rich lymph fluid increasesrich lymph fluid increasescellulitis.cellulitis.

Lacovora & Yoder, 2006Lacovora & Yoder, 2006

Low prophylactic doses of antibiotics may beLow prophylactic doses of antibiotics may be

used if patients develop cellulitis frequently.used if patients develop cellulitis frequently. Thiadens, 2005Thiadens, 2005

Cellulitis: used with

permission from

www.med-ars.it


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Stages ofLymphedema:Stages ofLymphedema:

StageIStageI Considered reversibleConsidered reversible

There is pitting and theThere is pitting and thetissue issofttissue issoft

Arm girth may or may not beArm girth may or may not be

increased.increased.

Treatment = elevationTreatment = elevation Lacovara & Yodder,Lacovara & Yodder,

20062006

There is > 3 cm differenceThere is > 3 cm difference

between extremitiesbetween extremities Itano & Taoka, 2005Itano & Taoka, 2005


lymphacare.com


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StageIIStageII

Considered irreversibleConsidered irreversible May be nonMay be non--pitting and fibroticpitting and fibrotic

Elevation does not reduce swelling.Elevation does not reduce swelling. Lacovara and Yoder, 2006Lacovara and Yoder, 2006

There is 3 to 5 cm difference betweenThere is 3 to 5 cm difference betweenextremities.extremities.

Itano & Taoka, 2005Itano & Taoka, 2005 Used with

permission from

lymphacare.com


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StageIIIStageIII Tissues are hard and may have cartilage formationTissues are hard and may have cartilage formation

developing.developing.

Swelling issevere and may form deep crevices.Swelling issevere and may form deep crevices. Lacovara and Yoder, 2006Lacovara and Yoder, 2006

There is a > 5 cm difference between extremities.There is a > 5 cm difference between extremities. Itano & Taoka, 2005Itano & Taoka, 2005

Photo Courtesy of Lymph Notes

(www.lymphnotes.com)


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StageIILymphedema is reversibleStageIILymphedema is reversible

TRUETRUE

Click on correct answerClick on correct answer

FALSEFALSE


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Correct! Stage II lymphedema isCorrect! Stage II lymphedema is

not reversible. With treatment,not reversible. With treatment,lymphedema may be minimized,lymphedema may be minimized,

but it is never truly cured.but it is never truly cured.

Continue on with the tutorial to learn about treatmentContinue on with the tutorial to learn about treatmentoptions!options!


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No, unfortunately Stage II lymphedemaNo, unfortunately Stage II lymphedema

is not reversible. With treatment, it is possibleis not reversible. With treatment, it is possibleto minimize the effect.to minimize the effect.

Continue with the tutorial to learn about treatmentContinue with the tutorial to learn about treatmentoptions!options!

Click here to return to QUESTIONClick here to return to QUESTION


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PreventionPrevention

No blood draws, IVs, blood pressures, orNo blood draws, IVs, blood pressures, orinjectionsshould be taken on the affectedinjectionsshould be taken on the affected

extremity.extremity. Thiadens, 2005Thiadens, 2005

This includes all needle sticks, such assubThis includes all needle sticks, such assub--q/IMq/IMinjections and finger pricks for blood sugar testing.injections and finger pricks for blood sugar testing.

Cole, 2006Cole, 2006


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The rationale is if any foreign object, such as aThe rationale is if any foreign object, such as a

needle, is placed in the affected extremity, itneedle, is placed in the affected extremity, itwill cause an inflammatory response.will cause an inflammatory response.

This puts the lymphatic system under moreThis puts the lymphatic system under more

stress, which may cause swelling to occur.stress, which may cause swelling to occur. Cole, 2006Cole, 2006


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Anything that may causeAnything that may cause

pressure needs to be avoided,pressure needs to be avoided,

including:including:

Blood pressure cuffsBlood pressure cuffs

TourequetsTourequets

Tight clothes (waist bands, bra straps, socks)Tight clothes (waist bands, bra straps, socks)

This constrictsThis constrictscollateral circulationcollateral circulation Dell & Doll, 2006Dell & Doll, 2006


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Good skin care:Good skin care: Keep the skin clean and dryKeep the skin clean and dry

Apply moisturizer dailyApply moisturizer daily

Protect skin with sunscreen and insect repellantProtect skin with sunscreen and insect repellant

Use care with razorsUse care with razors

Wear gloves when gardening, etc to protect the skinWear gloves when gardening, etc to protect the skin Keep cuts clean and dryKeep cuts clean and dry monitor closely for S & Smonitor closely for S & S

of infectionof infection

Contact physician immediately for rash, redness, pain,Contact physician immediately for rash, redness, pain,

increased swelling, etc.increased swelling, etc. Thiadens, 2005Thiadens, 2005


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Avoid extreme temperatures.Avoid extreme temperatures.

Heat may cause vasodilatation, which causes moreHeat may cause vasodilatation, which causes more

fluid to move from the blood vessels into the tissues.fluid to move from the blood vessels into the tissues.Avoid hot showers and saunas.Avoid hot showers and saunas.

Dell & Doll, 2006Dell & Doll, 2006

Cold may cause rebound swelling or chapped skinCold may cause rebound swelling or chapped skin Thiadens, 2005Thiadens, 2005


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Air travel > 2 hours increases the risk ofswelling becauseAir travel > 2 hours increases the risk ofswelling becauseof continuous reduction of cabin pressure.of continuous reduction of cabin pressure.

Dell & Doll, 2006Dell & Doll, 2006

It is recommended to wear a compression stocking whileIt is recommended to wear a compression stocking whileflying.flying.


Avoid carrying a purse, briefcase, or other heavy itemAvoid carrying a purse, briefcase, or other heavy itemwith the affected extremity.with the affected extremity.

If the lower extremity is affected, avoid standing orIf the lower extremity is affected, avoid standing orsitting for long periods of time and do not cross legs.sitting for long periods of time and do not cross legs.

Marrs, 2007Marrs, 2007


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Whatwouldbea goodmethodtoWhatwouldbea goodmethodto

identifyan effected/at riskextremity?identifyan effected/at riskextremity?(Clickon all ofthecorrectanswers)(Clickon all ofthecorrectanswers)

A. Have the patient carry a wallet card thatA. Have the patient carry a wallet card that

identifies affected extremity.identifies affected extremity. Use an ID bracelet or arm band to identifyUse an ID bracelet or arm band to identify

affected extremity.affected extremity.

Tie a string around the affected extremityTie a string around the affected extremity..

Click here to move to

TREATMENT OPTIONS


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Correct!Correct!

Many patients carry wallet cards to remind themselvesMany patients carry wallet cards to remind themselvesand healthcare provider of the affected extremity.and healthcare provider of the affected extremity.

Here is an example of what it looks like:Here is an example of what it looks like:


Courtesy of

www.lymphnotes.com


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Yes!Yes! Many patients will wear ID bracelets on the affectedMany patients will wear ID bracelets on the affected

extremity to alert healthcare providers to avoidextremity to alert healthcare providers to avoidvenipunctures, blood pressures, and fingersticks on thisvenipunctures, blood pressures, and fingersticks on thisextremity.extremity.

Here is an example:Here is an example:

Click here to return to questionClick here to return to question..


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IncorrectIncorrect

This is not an effective method of identification.This is not an effective method of identification.

If the string is too tight, it may constrict collateralIf the string is too tight, it may constrict collateralcirculation and cause lymphedema or makecirculation and cause lymphedema or make

existing lymphedema worse!existing lymphedema worse!



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TreatmentTreatment

Manual Lymph Drainage (MLD)Manual Lymph Drainage (MLD)

Performed byspecially trained therapistPerformed byspecially trained therapist

Massaging connective tissue rather that deep musclesMassaging connective tissue rather that deep muscles

Stimulates the weakened lymphatic system andStimulates the weakened lymphatic system anddecongests the affected area to encourage formation ofdecongests the affected area to encourage formation ofnew pathways to unimpaired lymph nodes to reducenew pathways to unimpaired lymph nodes to reduceswelling.swelling.

May also be taught to patient to perform on self.May also be taught to patient to perform on self. Thiadens, 2005; Dell & Doll, 2006Thiadens, 2005; Dell & Doll, 2006

Used with permission by

www.bellisse.com


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Compression BandagingCompression Bandaging

Bandages may be applied to increase tissueBandages may be applied to increase tissuepressure and counteract the elastic insufficiencypressure and counteract the elastic insufficiencyof the connective tissue.of the connective tissue.




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Once a manageable size has been achievedOnce a manageable size has been achieved

from wrapping, a compression stocking may befrom wrapping, a compression stocking may beworn to maintain the size and preventworn to maintain the size and preventincreased swelling.increased swelling.


Used with permission

By knueppels.com


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There are no medications available at this time toThere are no medications available at this time to

treat lymphedema.treat lymphedema.

Diureticsshould not be used to helpDiureticsshould not be used to helplymphedema because they draw off excess waterlymphedema because they draw off excess water

in the interstitial spaces, not the excess protein.in the interstitial spaces, not the excess protein.

Once the diuretic is out of the system, it pullsOnce the diuretic is out of the system, it pullsmore water into the affected areamore water into the affected area..

Holcomb, 2006Holcomb, 2006


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Nursing DiagnosisNursing Diagnosis

Impaired physical mobilityImpaired physical mobility

Disturbed body imageDisturbed body image

Risk for infectionRisk for infection Risk for impaired skin integrityRisk for impaired skin integrity



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Case Study:Case Study:

A 49 yearA 49 year--old woman diagnosed with infiltratingold woman diagnosed with infiltratingor invasive ductal carcinoma of the right breastor invasive ductal carcinoma of the right breastisscheduled for a mastectomy. To test theisscheduled for a mastectomy. To test the

lymph node involvement, a sentinel node biopsylymph node involvement, a sentinel node biopsyis performed, showing positive involvement. Ais performed, showing positive involvement. A

modified radical mastectomy is then performed,modified radical mastectomy is then performed,

removing all breast tissue and 15removing all breast tissue and 15--20 axillary20 axillarylymph nodes.lymph nodes.

How does this procedure put theHow does this procedure put the


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Howdoes this procedureputtheHowdoes this procedureputthe

patientat riskfor lymphedema?patientat riskfor lymphedema?

(Clickon thecorrectanswers)(Clickon thecorrectanswers)

A. There is minimal risk with this procedure.A. There is minimal risk with this procedure.

B. The lymphatic system needs time to heal itself,B. The lymphatic system needs time to heal itself,putting the patient at risk during this time.putting the patient at risk during this time.

C. This impairs the lymphatic flow in the axillaryC. This impairs the lymphatic flow in the axillary

region, making her more susceptible toregion, making her more susceptible to

lymphedema in the right arm.lymphedema in the right arm.


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IncorrectIncorrect

Any time there issurgical removal of any lymphAny time there issurgical removal of any lymph

node, the patient is at risk for lymphedema.node, the patient is at risk for lymphedema.

Please try the question again!Please try the question again!

Click here to returnClick here to return


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IncorrectIncorrect

The lymphatic system is not able to heal itself;The lymphatic system is not able to heal itself;

therefore, the risk of lymphedema is alwaystherefore, the risk of lymphedema is alwayspresent.present.

Please try the question again!Please try the question again!

Click here to return to the questionClick here to return to the question


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Correct!Correct!

When the lymphatic flow is impaired or obstructed,When the lymphatic flow is impaired or obstructed,the risk of lymphedema increases.the risk of lymphedema increases.

Area of concern


cancerbackup.org

Click here togo to the nextquestion

H h i h i i k fH h i h i i k f


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Howmuch is thepatients riskforHowmuch is thepatients riskfor

lymphedema increaseddueto axillarylymphedema increaseddueto axillary

node involvement?node involvement?(Clickon thecorrectanswer)(Clickon thecorrectanswer)

A. No increaseA. No increase

B. 5%B. 5%

C. 10C. 10 -- 15%15%

D. 30D. 30 -- 60%60% Golshan & Smith, 2006Golshan & Smith, 2006


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Nope!Nope!

Any time there is lymph node involvement, thereAny time there is lymph node involvement, there

is a risk of lymphedemais a risk of lymphedema

Try again!Try again!

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IncorrectIncorrect

5% seems a bit low.5% seems a bit low.

Please try again!Please try again!

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Try AgainTry Again

55--10% is not the correct answer.10% is not the correct answer.

Please try again.Please try again.

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Correct!Correct!

The risk is 30The risk is 30--60%, which is pretty high!60%, which is pretty high!

This is why it isso important to educate yourThis is why it isso important to educate yourpatients and fellow nurses on prevention!patients and fellow nurses on prevention!

Click here to go to the next question.Click here to go to the next question.

Identify methods of prevention youIdentify methods of prevention you


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Identifymethods ofprevention youIdentifymethods ofprevention you

willwantto teachyour patient:willwantto teachyour patient:

(Clickon screen for answers)(Clickon screen for answers)

Good skin careGood skin care Clean and dryClean and dry

MoisturizeMoisturize Use sunscreenUse sunscreen

Use electric razorsUse electric razors

Wear gardening glovesWear gardening gloves

Keep cuts clean and dryKeep cuts clean and dry Contact MD for any S &Contact MD for any S &

S of infectionS of infection

Avoid extremeAvoid extremetemperaturestemperatures

Encourage caution withEncourage caution withair travelair travel

Avoid carrying heavyAvoid carrying heavythings/extreme motionsthings/extreme motions

No bloodNo blooddraws/IVs/BPs/fingerdraws/IVs/BPs/fingersticks in R arm!!!sticks in R arm!!!

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After receiving chemotherapy, she is admittedAfter receiving chemotherapy, she is admitted

for a neutropenic fever. When doing aphysicalfor a neutropenic fever. When doing aphysical

assessment, whatthings shouldyou beassessment, whatthings shouldyou bewatching for withher rightarm?watching for withher rightarm?

Swelling in the right armSwelling in the right arm

onlyonly Any edema (pitting orAny edema (pitting or

nonnon--pitting)pitting)

W

atch for any redness

W

atch for any redness

and tight rings, watches,and tight rings, watches,or bracelets.or bracelets.

A feeling of heaviness,A feeling of heaviness,

achiness, tingling,achiness, tingling,numbness, or weaknessnumbness, or weaknessin the R arm reported byin the R arm reported bythe patient.the patient.

Click on screen for answers

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You observe these signs andYou observe these signs and


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You observethese signs andYou observethese signs and

symptoms in her Rarm. Whataresymptoms in her Rarm. Whatare

her treatment options?her treatment options?(Clickon allcorrectanswers)(Clickon allcorrectanswers)

A. MLDA. MLD Manual Lymphatic drainageManual Lymphatic drainage

B. Wrapping the extremityB. Wrapping the extremity

C. Compression garmentC. Compression garment

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YES!YES! MLDMLD Manual lymphManual lymph

drainage is a gentledrainage is a gentlemassage performed inmassage performed inthe affected area to helpthe affected area to helpmove the lymph fluidmove the lymph fluidback in the appropriateback in the appropriatedirection.direction.

It should be performedIt should be performed

at least once a day forat least once a day forabout 10about 10--15 minutes.15 minutes.

Academy ofAcademy of

Lymphatic Studies,Lymphatic Studies,

20062006

Used with permission by

www.bellisse.com

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Correct!Correct!

After MLD isAfter MLD is

performed, theperformed, theextremityshould beextremityshould be

wrapped to reducewrapped to reduceand soften fibroticand soften fibrotic

tissue.tissue. Academy ofAcademy of

Lymphatic Studies,Lymphatic Studies,20062006

Used with permission fromlymphacare.com

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Right!Right!

Once the extremity isOnce the extremity isa manageable size, aa manageable size, a

compression stockingcompression stocking

should be worn toshould be worn tomaintain thissize.maintain thissize. Thiadens, 2005Thiadens, 2005

Used with permissionBy knueppels.com

Click HERE to return toquestion

What are some possible nursingWhat are some possible nursing


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Whatare somepossible nursingWhatare somepossible nursing

outcomes?outcomes?

(Clickon allpossibleanswers)(Clickon allpossibleanswers)

A. Impaired physical mobilityA. Impaired physical mobility

B. Disturbed body imageB. Disturbed body image C. Risk for infectionC. Risk for infection

D. Risk for impaired skin integrityD. Risk for impaired skin integrity Itano & Taoka, 2005Itano & Taoka, 2005

Click HERE to END tutorial


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Right!Right!

Lymphedema can make mobility difficult,Lymphedema can make mobility difficult,especially lower extremity lymphedema.especially lower extremity lymphedema.

It is important to assess your patient and refer toIt is important to assess your patient and refer to

physical therapy for exercises and activityphysical therapy for exercises and activityrestrictions.restrictions.


lymphacare.com

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question


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Correct!Correct!

A patient with lymphedema may have aA patient with lymphedema may have a

disturbed body image from such things asdisturbed body image from such things aswearing overwearing over--sized clothes or two different sizedsized clothes or two different sized

shoes.shoes.

It is important to address these things with yourIt is important to address these things with your

patient.patient.



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Yes!Yes!

Infection may be commonInfection may be commonin lymphedema; pooling ofin lymphedema; pooling of

proteinprotein--rich lymph fluidrich lymph fluid

increases cellulitis.increases cellulitis. Lacovora & Yoder, 2006Lacovora & Yoder, 2006 Low prophylactic doses ofLow prophylactic doses of

antibiotics may be used ifantibiotics may be used ifpatients develop cellulitispatients develop cellulitisfrequently.frequently.


Cellulitis: used with

permission fromwww.med-ars.it

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Correct!Correct!

Skin on the affected arm may be more dry thanSkin on the affected arm may be more dry than

normalnormal.. Academy ofLymphatic Studies, 2006Academy ofLymphatic Studies, 2006

Good skin care is essential to prevent infection;Good skin care is essential to prevent infection;wraps and compression stockings may retainwraps and compression stockings may retainmoisture against the skin.moisture against the skin.



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CONGRATULATIONS!CONGRATULATIONS!

You have successfully completed theYou have successfully completed thetutorial!!tutorial!!

Click HERE to view REFERENCESClick HERE to view REFERENCES


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ReferencesReferences

Academy ofLymphatic Studies (2006) The source for research basedAcademy ofLymphatic Studies (2006) The source for research basedlymphedema management. CD Rom. Sebastian, FL. ACOLSlymphedema management. CD Rom. Sebastian, FL. ACOLS Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R. (2006).Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R. (2006).

Exercise for women with or at risk for breast cancerExercise for women with or at risk for breast cancer--related lymphedema.related lymphedema.Physical Therapy.Physical Therapy. 86 (10). pp. 139886 (10). pp. 1398--1405.1405.

Cole, T. (2006). Risks and benefits of needle use in patients after axillary nodeCole, T. (2006). Risks and benefits of needle use in patients after axillary nodesurgery.surgery. British Journal of NursingBritish Journal of Nursing15(18) pp. 96915(18) pp. 969--979.979.

Dell, D.D. (2005). Spread the word about breast cancer.Dell, D.D. (2005). Spread the word about breast cancer.Nursing2005Nursing200535(10).35(10).pp56pp56--6363

Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema.Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema.Nursing2006.Nursing2006.36(6). pp. 4936(6). pp. 49--51.51.

Dow, K.H. (2002). Pocket guide to breast cancer (2Dow, K.H. (2002). Pocket guide to breast cancer (2ndnd ed). Sudbury, MA: Jonesed). Sudbury, MA: Jonesand Bartlett Publishers.and Bartlett Publishers.

Golshan, M., Smith, B. (2006). Prevention and management of armGolshan, M., Smith, B. (2006). Prevention and management of armlymphedema in the patient with breast cancer.lymphedema in the patient with breast cancer. Supportive OncologySupportive Oncology4(8). pp.4(8). pp.381381--386386


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Holcomb, S.S. (2006). Putting the squeeze on lymphedema.Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Nursing MadeNursing MadeIncredibly Easy!Incredibly Easy!4(2). Pp264(2). Pp26--34.34.

Itano, J.K., Taoka, K.N. (2005).Itano, J.K., Taoka, K.N. (2005). Core curriculum for oncology nursingCore curriculum for oncology nursing(4(4thth ed)ed)Philadelphia, PA: Elsevier Saunders.Philadelphia, PA: Elsevier Saunders.

Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the cancer patient.Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the cancer patient.MEDSURG Nursing.MEDSURG Nursing. 15(5). pp. 30215(5). pp. 302--306.306.

Lewis, M.S., Heitkemper, M.M., Dirsken, S.R. (2000).Lewis, M.S., Heitkemper, M.M., Dirsken, S.R. (2000). MedicalMedical--surgical nursing:surgical nursing:assessment and management of clinical problemsassessment and management of clinical problems. St. Louis, MO: Mosby.. St. Louis, MO: Mosby.

Mader, S. (1994).Mader, S. (1994). Understanding human anatomy and physiologyUnderstanding human anatomy and physiology(2(2ndnd ed).ed). Dubuque,Dubuque,IA: Wm. C. Brown Publishers.IA: Wm. C. Brown Publishers.

Marrs, J. (2007). Lymphedema and implications for oncology nursing practice.Marrs, J. (2007). Lymphedema and implications for oncology nursing practice.Clinical Journal of Oncology Nursing.Clinical Journal of Oncology Nursing. 11(1). pp. 1911(1). pp. 19--21.21.

National Cancer Institute (2006).National Cancer Institute (2006).www.cancer.govwww.cancer.gov.. retrieved 4/5/07retrieved 4/5/07 Nazarko, L. (2006). Understanding lymphedema in older people.Nazarko, L. (2006). Understanding lymphedema in older people.Nursing &Nursing &

ResidentialCare.ResidentialCare. 8 (6). Pp.2548 (6). Pp.254--258.258.


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Porth, C.M. (2005)Porth, C.M. (2005)Pathophysiology: concepts of altered health statesPathophysiology: concepts of altered health states(7(7thth ed). Philadelphia, PA:ed). Philadelphia, PA:

Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.

Romero, R. (2007). Bandaging options for head and neck edema.Romero, R. (2007). Bandaging options for head and neck edema. eLymphnotes.eLymphnotes. RetrievedRetrieved

from www.elymphnotes.orgfrom www.elymphnotes.org

Thiadens, S.R.J., (2005).Thiadens, S.R.J., (2005). Lymphedema: an information booklet.Lymphedema: an information booklet. (8(8thth ed). Oakland, CA: Nationaled). Oakland, CA: National

Lymphedema Network.Lymphedema Network.

Special Thanks To The FollowingSpecial Thanks To The Following


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Special Thanks To The FollowingSpecial Thanks To The Following

For Permission To Use Graphics!For Permission To Use Graphics!

Bellisse.comBellisse.com

Bocaradiology.comBocaradiology.com

Cancerbackup.orgCancerbackup.org

Knueppels.comKnueppels.com

Lymphacare.comLymphacare.com

Lymphnotes.comLymphnotes.com

MedMed--ars.itars.it

Vascularsociety.orgVascularsociety.org

Special thanks to AnnSpecial thanks to Annfrom lymphnotes.comfrom lymphnotes.com

for sending wallet cardsfor sending wallet cardsand handouts and to myand handouts and to mypreceptor, Julie Griffie,preceptor, Julie Griffie,for all of her support.for all of her support.

Lymph Edema Tutorial (1)

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