Download Lymphedema - Laura Kupperman

Lymphedema
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Objectives
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Understand/describe the normal structure and
function of the lymphatic system.
Identify risk factors affecting the normal drainage
of the lymphatic system.
Discuss diseases or procedures that could
predispose a patient to lymphedema.
What is lymphedema?

Lymphedema is an
abnormal
accumulation of
high-protein
concentrated fluid,
usually in the arms
and legs.

Dell & Doll, 2006
Image reproduced with permission
from vascularsociety.org
The Lymphatics

The lymphatic system
filters and collects
lymph and large
molecules in the
interstitial space that
come from the
intravascular space.

Golshan & Smith, 2006
Used with permission from lymphacare.com

Normally, the heart pumps so strongly that it
causes 20-30 liters of plasma per day to leak
from the capillaries. This is the interstitial fluid,
which the lymphatic system drains, filters, and
returns to the heart.

Nazarko, 2006
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This interstitial fluid contains proteins, lipids, water,
and products from cellular breakdown.
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Golshan & Smith, 2006
Lymphatic vessels are similar to veins, but with
thinner walls to allow larger proteins to permeate
through.
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Holcomb, 2006
National Cancer Institute, 2006
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Once this interstitial fluid is
absorbed, it moves through
the lymphatic vessels, and is
considered lymph fluid.
As lymph fluid moves
through the lymphatic
system, it passes through
lymph nodes. Lymph nodes
filter harmful substances
and contain lymphocytes
that activate the immune
system.

National Cancer Institute,
2006
Used with permission from
Lymphnotes.com

The lymph system carries the lymphocytes
throughout the body to respond to antigens and
communicate responses to other parts of the
body.

Lacovara & Yoder, 2006
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Lymph then travels through multiple lymphatic channels
and nodes before returning to the venous system by the
thoracic duct.

Golshan and Smith, 2006
Used with permission by med-ars.it

Under normal
conditions, the entry of
fluid and other materials
into the interstitial space
is balanced by outflow
of the lymphatic fluid
from the limb, which
maintains standard
volume.

Golshan and Smith,
2006
Used with permission
from www.med-ars.it

Lymphedema occurs when there is an interruption or
obstruction of the lymphatic system that causes an
accumulation of fluid in the limb.

Golshan & Smith, 2006
Used with
permission
from
lymphacare
.com

A healthy adult has approximately 600-700 lymph
nodes.


Lacovara & Yoder, 2006
The main areas are:
Supraclavicular
 Retroperitoneal (deep abdomen and pelvis)
 Trachea
 Thoracic (adjacent to the lung)


Thiadens, 2005
 Abdominal
(near the intestine)
 Axilla
 The
pelvic area
 Inguinal
 Also found in tonsils,
spleen, intestinal wall,
and bone marrow.

Thiadens, 2005
Review of the “Flow”
Click on the screen
Interstitial fluid has
diffused from blood
capillaries
The lymph capillaries
absorb this interstitial
fluid
The capillaries join
to form vessels that
carry the lymph fluid
back to the heart.
Thoracic Duct
The lymph fluid then
enters either the thoracic
duct or right lymphatic duct
On the trip back, the
lymph fluid passes
through lymph nodes,
where it is cleaned and
filtered
Mader, 1994
www.lymphacare.com
The fluid is then enters the
subclavian veins and is returned
to the circulatory system.
Risk Factor: Surgery

Any surgery that dissects or removes lymph nodes
increases the risk of lymphedema by impairing the
lymph flow.
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
Marrs, 2007; Lacovara & Yoder, 2006
Common cancers that may require surgical
alterations of the lymph nodes include breast
cancer, melanoma, gynecological cancers, head
and neck, prostate, testicular, bladder, or colon
cancer.

Thiadens, 2005
Risk Factor: Obstruction
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Tumors themselves may cause lymphedema by
obstructing the lymphatic vessels.
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Dell & Doll, 2006
This is can be seen with many cancers, including
cervical cancer, breast and prostate cancer, and
head and neck cancers.

Nazarko, 2006; Romero, 2007.
Risk Factor: Radiation
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Radiation therapy to the
axillary or groin region
around the lymph node can
cause fibrosis and scarring of
the tissue and therefore
cause lymphedema to occur.

Golshan & Smith, 2006
Risk Factor: Lymphedema
and Breast Cancer
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It is estimated that that anywhere from 25-60%
of patients with breast cancer will experience
lymphedema.

Lacova & Yoder, 2006
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The sentinel lymph node is the first lymph node
draining from this tumor bed.
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Tumor
Dow, 2002
Sentinel Node
Used with permission from www.med-ars.it

A technique called Sentinel Node Biopsy can be
performed, which the surgeon finds and removes
this first node and sends it for a pathologic
examination.
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New evidence suggests that there is no need to
remove any more lymph nodes regardless of the
pathology-- the SNB pathlogy gives the physician
the info needed to design treatment protocol.

Thaidens, 2005
Lymph node anatomy
Used with permission from
Bocaradiology.org
Other Risks: Infection and Injury
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Things such as infections, bug bites, and bee
stings may lead to lymphedema in a high-risk
patient.
Trauma to the extremity at risk may also cause
lymphedema. What constitutes trauma?
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The rationale is lymphatic flow increases to the
affected site, however there is an obstruction or
defect in the lymphatic system, causing lymph fluid to
leak.

Dell & Doll, 2006
Other Possible Risks:
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Other causes that may lead to lymphedema include:
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Scarring from a vesicant extravasation
Local burns
Lymph node metastasis
Overexercise, including stretching of cord
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Cording or Axillary webbing
Diagnosing Lymphedema
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Painless swelling of the arms or legs, which may
get worse during the day and better at night.
Warmth or achiness in the extremity.
A feeling of tightness, heaviness, tingling,
numbness, or weakness in the affected extremity.
Redness of the affected extremity.
Bracelets, rings, or shoes may become tight.
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Lacovara & Yoder, 2006
Diagnosis, Continued…
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A 2 cm difference between affected extremity
and non-affected extremity is a general
classification.

Bicego, et al, 2006
Infection
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Infection may be common in lymphedema;
pooling of protein-rich lymph fluid increases
cellulitis.
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Lacovora & Yoder, 2006
Low prophylactic doses of antibiotics may be
used if patients develop cellulitis frequently.
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Thiadens, 2005
Cellulitis: used with
permission from
www.med-ars.it
Stages of Lymphedema:
Stage I
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Considered reversible
There is pitting and the
tissue is soft
Arm girth may or may not be
increased.
Treatment = elevation
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Lacovara & Yodder,
2006
There is > 3 cm difference
between extremities

Itano & Taoka, 2005
Used with permission from
lymphacare.com
Stage II
Considered irreversible
 May be non-pitting and fibrotic
 Elevation does not reduce swelling.
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Lacovara and Yoder, 2006
There is 3 to 5 cm difference between
extremities.

Itano & Taoka, 2005
Used with
permission from
lymphacare.com
Stage III
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Tissues are hard and may have cartilage formation
developing.
Swelling is severe and may form deep crevices.
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Lacovara and Yoder, 2006
There is a > 5 cm difference between extremities.
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Itano & Taoka, 2005
Photo Courtesy of Lymph Notes
(www.lymphnotes.com)
Prevention
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No blood draws, IVs, blood pressures, or
injections should be taken on the affected
extremity.
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Thiadens, 2005
This includes all needle sticks, such as sub-q/IM
injections and finger pricks for blood sugar testing.

Cole, 2006
 The
rationale is if any foreign object, such as a
needle, is placed in the affected extremity, it
will cause an inflammatory response.
 This puts the lymphatic system under more
stress, which may cause swelling to occur.

Cole, 2006
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A general recommendation is to avoid having
blood pressure taken in that extremity, avoid
tight clothes, rings, etc. but recent research
suggests that this might not be a risk factor.
Normalize body weight
Progressive exercise programs
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Good skin care:
Keep the skin clean and dry
 Apply moisturizer daily
 Protect skin with sunscreen and insect repellant
 Use care with razors
 Wear gloves when gardening, etc to protect the skin
 Keep cuts clean and dry – monitor closely for S & S
of infection
 Contact physician immediately for rash, redness, pain,
increased swelling, etc.
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Thiadens, 2005
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Avoid extreme temperatures, such as hot tubs
and saunas.
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Heat may cause vasodilatation, which causes more fluid to
move from the blood vessels into the tissues.
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Dell & Doll, 2006
Cold may cause rebound swelling or chapped skin,
leading to infection.
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Air travel has been thought to be a risk factor for
lymphedema, but recent research does not support this,
except for those who have a high number of nodes
removed, for e.g. 15+. For these individuals, wearing a
compression sleeve MAY prevent lymphedema.
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If the lower extremity is affected, avoid standing or
sitting for long periods of time and do not cross legs.
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Marrs, 2007
Treatment
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Used with permission by
www.bellisse.com
Manual Lymph Drainage (MLD)
Performed by specially trained therapist
 Massaging connective tissue rather that deep muscles
 Stimulates the lymphatic system and decongests the
affected area to encourage formation of new pathways
to unimpaired lymph nodes to reduce swelling.
 May also be taught to patient to perform on self.
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Thiadens, 2005; Dell & Doll, 2006
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Compression Bandaging
 Bandages
may be applied to increase tissue
pressure and counteract the elastic insufficiency
of the connective tissue.

Thiadens, 2005
Used with permission from lymphacare.com
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Once a manageable size has been achieved
from wrapping, a compression stocking may be
worn to maintain the size and prevent
increased swelling.

Thiadens, 2005
Used with permission
By knueppels.com
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There are no medications available at this time to
treat lymphedema.
Diuretics should not be used to help
lymphedema because they draw off excess water
in the interstitial spaces, not the excess protein.
Once the diuretic is out of the system, it pulls
more water into the affected area.

Holcomb, 2006
DISABILITY
Impaired physical mobility
 Disturbed body image
 Risk for infection
 Risk for impaired skin integrity
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Itano & Taoka, 2005
References
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Academy of Lymphatic Studies (2006 ) The source for research based
lymphedema management. CD Rom. Sebastian, FL. ACOLS
Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R. (2006).
Exercise for women with or at risk for breast cancer-related lymphedema.
Physical Therapy. 86 (10). pp. 1398-1405.
Cole, T. (2006). Risks and benefits of needle use in patients after axillary node
surgery. British Journal of Nursing 15(18) pp. 969-979.
Dell, D.D. (2005). Spread the word about breast cancer. Nursing2005 35(10).
pp56-63
Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema. Nursing2006.
36(6). pp. 49-51.
Dow, K.H. (2002). Pocket guide to breast cancer (2nd ed). Sudbury, MA: Jones
and Bartlett Publishers.
Golshan, M., Smith, B. (2006). Prevention and management of arm
lymphedema in the patient with breast cancer. Supportive Oncology 4(8). pp.
381-386
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Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Nursing Made
Incredibly Easy! 4(2). Pp26-34.
Itano, J.K., Taoka, K.N. (2005). Core curriculum for oncology nursing (4th ed)
Philadelphia, PA: Elsevier Saunders.
Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the cancer patient.
MEDSURG Nursing. 15(5). pp. 302-306.
Lewis, M.S., Heitkemper, M.M., Dirsken, S.R. (2000). Medical-surgical nursing:
assessment and management of clinical problems. St. Louis, MO: Mosby.
Mader, S. (1994). Understanding human anatomy and physiology (2nd ed).
Dubuque,
IA: Wm. C. Brown Publishers.
Marrs, J. (2007). Lymphedema and implications for oncology nursing practice.
Clinical Journal of Oncology Nursing. 11(1). pp. 19-21.
National Cancer Institute (2006). www.cancer.gov. retrieved 4/5/07
Nazarko, L. (2006). Understanding lymphedema in older people. Nursing &
Residential Care. 8 (6). Pp.254-258.
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Porth, C.M. (2005) Pathophysiology: concepts of altered health states (7th ed). Philadelphia, PA:
Lippincott Williams & Wilkins.
Romero, R. (2007). Bandaging options for head and neck edema. eLymphnotes. Retrieved
from www.elymphnotes.org
Thiadens, S.R.J., (2005). Lymphedema: an information booklet. (8th ed). Oakland, CA: National
Lymphedema Network.