Transcript Lymphedema - Student Nurse Journey

Lymphedema
Emily Richter, RN, BSN, OCN
Alverno College
Spring 2007
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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.
Explain assessment of a patient with lymphedema.
Describe nursing interventions to promote lymphatic
drainage for a patient with lymphedema.
Participate in a case study
Table of Contents

Choose a topic listed below to go to that section
of the tutorial.
1. Pathophysiology
2. Risk Factors
3. Diagnosis
4. Prevention and
Treatment
5. Nursing Diagnoses
6. Case Study
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.


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

Lymph vessels usually do not have a large basement
membrane, which allows large molecules to enter
that cannot be reabsorbed readily by the venous
system.

Golshan and Smith, 2006
Used with permission by www.med-ars.it
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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
Identify Major Lymph Nodes
Click on the body
Spleen
Cervical Nodes
Axillary Nodes
Inguinal Nodes
Used with permission from cancerbackup.org
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.
Why is the lymphatic system so
important?
(Click on all correct answers)
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A. The lymph system collects excess tissue fluid.

B. It plays a major role in the body’s defense
against disease.
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C. It circulates blood throughout the body
Right!

The lymph system absorbs interstitial
fluid and returns it back to the blood
circulation.
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Click here to return to question
Correct!

The lymph system circulates lymphocytes, such
as T Cells, B Cells, and NK Cells.

Click here to return to question
Incorrect

This is a different system…. the lymphatic
system contains fluid, not blood.

Click here to return to question
Risk Factor: Surgery

Any surgery that dissects or removes lymph nodes
increases the risk of lymphedema by impairing the
lymph flow.


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.


Dell & Doll, 2006
This is can be seen with cervical cancer, prostate
cancer, or head and neck cancer.

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 15-20% of patients with
breast cancer will experience lymphedema.

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Lacova & Yoder, 2006
The tumor bed in the breast may drain into the
lymphatics.

Dow, 2002
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The sentinel lymph node is the first lymph node
draining from this tumor bed.

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.


Dell, 2005
If the sentinel node is benign, no further lymph
node removal is needed.

Thaidens, 2005

However if the
sentinel node is
positive, the axillary
nodes may need to be
removed, which
increases the chances
of lymphedema by
30-60%.

Golshan and Smith, 2006
Used with permission from
Bocaradiology.org
Other Risks: Infection and Injury


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.

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:

Other causes that may lead to lymphedema
include:
Scarring from a vesicant extravasation
 Local burns
 Lymph node metastasis


Itano & Taoka, 2005
Review: What cancers can be
associated with lymphedema?
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Malignant Melanoma
Gynecological
Cancers
Head and Neck
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Colon
Prostate/Bladder
Sarcoma
Click on all of the
correct answers
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Correct! Malignant Melanoma can lead to lymphedema.
Here’s how:
Malignant melanoma can metastasize to regional lymph
nodes. Treatment for malignant melanoma may
involve surgical resection; depending on location and
extent of disease, the lymph nodes may need to be
removed.

Click here
to return
to question
Itano & Taoka, 2005
Possible risk areas:
Axillary Nodes
Inguinal Nodes
www.
cancebackup.
org

Right! Here’s how:

When you think of gynecologic cancers (ovarian, uterine,
cervical), think location. Surgical removal of the inguinal
lymph nodes puts the patient at risk for lower extremity
lymphedema.
Click HERE to return
to question
www.
cancebackup.
org
Inguinal Nodes
Correct! Head and Neck cancer
can cause lymphedema.
Here’s how:
 Squamous cell carcinoma occurring in the head and
neck may obstruct lymph nodes or require removal
of near by nodes.
 A common treatment of head and neck cancer also
includes radiation.
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Romero, 2007
Click HERE to return to question
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Right! Here’s how colon cancer can lead to
lymphedema:
Tumors can invade beyond the submucosal layer
and have direct access to the lymphatic system.
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Itano & Taoka, 2005
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Treatment for colon cancer includes surgery and
radiation, which may damage regional lymph
nodes.
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Click HERE to return to question

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Good! Let’s look at how prostate and
bladder cancer can lead to lymphedema:
In advanced bladder cancer, a cystectomy
may be performed, removing the bladder,
prostate (men) and hysterectomy (women).
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Itano & Taoka, 2005
Radiation is also a method of treatment for advanced
stages, putting regional lymph nodes at risk.
This patient would be at risk for lower extremity
lymphedema.
Click HERE to return to question
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Yes! Sarcoma can lead to
lymphedema. Here’s how:
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The goal of treatment for
sarcoma is surgical removal.
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Itano & Taoka, 2005
Depending on location, lymph nodes may be damaged of
removed
Radiation may be used to reduce tumor size. This also
puts lymph nodes at risk for fibrosis.
Click HERE to return to question
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.

Lacovara & Yoder, 2006
Diagnosis, Continued…
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A 2 cm difference between affected extremity
and non-affected extremity is a general
classification.
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Bicego, et al, 2006
Tends to occur distal to proximal
Increased pigmentation/superficial veins
Secondary cellulitis

Itano & Taoka, 2005
Infection
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Infection may be common in lymphedema;
pooling of protein-rich lymph fluid increases
cellulitis.


Lacovora & Yoder, 2006
Low prophylactic doses of antibiotics may be
used if patients develop cellulitis frequently.

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.



Lacovara and Yoder, 2006
There is 3 to 5 cm difference between
extremities.

Itano & Taoka, 2005
Used with
permission from
lymphacare.com
Stage III


Tissues are hard and may have cartilage formation
developing.
Swelling is severe and may form deep crevices.


Lacovara and Yoder, 2006
There is a > 5 cm difference between extremities.

Itano & Taoka, 2005
Photo Courtesy of Lymph Notes
(www.lymphnotes.com)
Stage II Lymphedema is reversible

TRUE

Click on correct answer

FALSE

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Correct! Stage II lymphedema is
not reversible. With treatment,
lymphedema may be minimized,
but it is never truly “cured”.
Continue on with the tutorial to learn about treatment
options!



No, unfortunately Stage II lymphedema
is not reversible. With treatment, it is possible
to minimize the effect.
Continue with the tutorial to learn about treatment
options!
Click here to return to QUESTION
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

Anything that may cause
pressure needs to be avoided,
including:
Blood pressure cuffs
 Tourequets
 Tight clothes (waist bands, bra straps, socks)


This constricts collateral circulation

Dell & Doll, 2006

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.


Thiadens, 2005

Avoid extreme temperatures.

Heat may cause vasodilatation, which causes more
fluid to move from the blood vessels into the tissues.
Avoid hot showers and saunas.


Dell & Doll, 2006
Cold may cause rebound swelling or chapped skin

Thiadens, 2005

Air travel > 2 hours increases the risk of swelling because
of continuous reduction of cabin pressure.
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
It is recommended to wear a compression stocking while
flying.
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

Dell & Doll, 2006
Thiadens, 2005
Avoid carrying a purse, briefcase, or other heavy item
with the affected extremity.
If the lower extremity is affected, avoid standing or
sitting for long periods of time and do not cross legs.

Marrs, 2007
What would be a good method to
identify an effected/at risk extremity?
(Click on all of the correct answers)



A. Have the patient carry a wallet card that
identifies affected extremity.
Use an ID bracelet or arm band to identify
affected extremity.
Tie a string around the affected extremity.
Click here to move to
TREATMENT OPTIONS
Correct!


Many patients carry wallet cards to remind themselves
and healthcare provider of the affected extremity.
Here is an example of what it looks like:
Courtesy of
www.lymphnotes.com

Click here to return to question
Yes!

Many patients will wear ID bracelets on the affected
extremity to alert healthcare providers to avoid
venipunctures, blood pressures, and fingersticks on this
extremity.
Here is an example:

Click here to return to question.

Incorrect



This is not an effective method of identification.
If the string is too tight, it may constrict collateral
circulation and cause lymphedema or make
existing lymphedema worse!
Click here to return to question
Treatment

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 weakened 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.


Thiadens, 2005; Dell & Doll, 2006
Used with permission from lymphacare.com

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

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


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
Nursing Diagnosis
Impaired physical mobility
 Disturbed body image
 Risk for infection
 Risk for impaired skin integrity


Itano & Taoka, 2005
Case Study:

A 49 year-old woman diagnosed with infiltrating
or invasive ductal carcinoma of the right breast
is scheduled for a mastectomy. To test the
lymph node involvement, a sentinel node biopsy
is performed, showing positive involvement. A
modified radical mastectomy is then performed,
removing all breast tissue and 15-20 axillary
lymph nodes.
How does this procedure put the
patient at risk for lymphedema?
(Click on the correct answers)



A. There is minimal risk with this procedure.
B. The lymphatic system needs time to heal itself,
putting the patient at risk during this time.
C. This impairs the lymphatic flow in the axillary
region, making her more susceptible to
lymphedema in the right arm.
Incorrect

Any time there is surgical removal of any lymph
node, the patient is at risk for lymphedema.

Please try the question again!

Click here to return
Incorrect

The lymphatic system is not able to heal itself;
therefore, the risk of lymphedema is always
present.

Please try the question again!

Click here to return to the question
Correct!

When the lymphatic flow is impaired or obstructed,
the risk of lymphedema increases.
Area of concern
Click here to
go to the next
question
Used with permission from
cancerbackup.org
How much is the patients risk for
lymphedema increased due to axillary
node involvement?
(Click on the correct answer)



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A. No increase
B. 5%
C. 10 - 15%
D. 30 - 60%

Golshan & Smith, 2006
Nope!

Any time there is lymph node involvement, there
is a risk of lymphedema

Try again!

Click here to return to the question
Incorrect

5% seems a bit low….

Please try again!

Click here to return to question.
Try Again

5-10% is not the correct answer.

Please try again.

Click here to return to the question.
Correct!

The risk is 30-60%, which is pretty high!
This is why it is so important to educate your
patients and fellow nurses on prevention!

Click here to go to the next question.

Identify methods of prevention you
will want to teach your patient:
(Click on screen for answers)

Good skin care

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




Clean and dry
Moisturize
Use sunscreen
Use electric razors
Wear gardening gloves
Keep cuts clean and dry
Contact MD for any S &
S of infection




Avoid extreme
temperatures
Encourage caution with
air travel
Avoid carrying heavy
things/extreme motions
No blood
draws/IVs/BPs/finger
sticks in R arm!!!
Click here to go to the next question
After receiving chemotherapy, she is admitted
for a neutropenic fever. When doing a physical
assessment, what things should you be
watching for with her right arm?



Swelling in the right arm
only
Any edema (pitting or
non-pitting)
Watch for any redness
and tight rings, watches,
or bracelets.

A feeling of heaviness,
achiness, tingling,
numbness, or weakness
in the R arm reported by
the patient.
Click on screen for answers
Click HERE to go to the next question
You observe these signs and
symptoms in her R arm. What are
her treatment options?
(Click on all correct answers)

A. MLD – Manual Lymphatic drainage

B. Wrapping the extremity

C. Compression garment
Click HERE to go to next question
YES!


MLD – Manual lymph
drainage is a gentle
massage performed in
the affected area to help
move the lymph fluid
back in the appropriate
direction.
It should be performed
at least once a day for
about 10-15 minutes.

Academy of
Lymphatic Studies,
2006
Used with permission by
www.bellisse.com
Click HERE to return
to question
Correct!

After MLD is
performed, the
extremity should be
wrapped to reduce
and soften fibrotic
tissue.

Academy of
Lymphatic Studies,
2006
Used with permission from
lymphacare.com
Click HERE to return to question
Right!

Once the extremity is
a manageable size, a
compression stocking
should be worn to
maintain this size.

Thiadens, 2005
Click HERE to return to
question
Used with permission
By knueppels.com
What are some possible nursing
outcomes?
(Click on all possible answers)




A. Impaired physical mobility
B. Disturbed body image
C. Risk for infection
D. Risk for impaired skin integrity

Itano & Taoka, 2005
Click HERE to END tutorial
Right!


Lymphedema can make mobility difficult,
especially lower extremity lymphedema.
It is important to assess your patient and refer to
physical therapy for exercises and activity
restrictions.
Click HERE to return to
question
Used with permission from
lymphacare.com
Correct!


A patient with lymphedema may have a
disturbed body image from such things as
wearing over-sized clothes or two different sized
shoes.
It is important to address these things with your
patient.
Click HERE to return to question
Yes!

Infection may be common
in lymphedema; pooling of
protein-rich lymph fluid
increases cellulitis.


Lacovora & Yoder, 2006
Low prophylactic doses of
antibiotics may be used if
patients develop cellulitis
frequently.

Thiadens, 2005
Cellulitis: used with
permission from
www.med-ars.it
Click HERE to
return to question
Correct!

Skin on the affected arm may be more dry than
normal.


Academy of Lymphatic Studies, 2006
Good skin care is essential to prevent infection;
wraps and compression stockings may retain
moisture against the skin.
Click HERE to return to question
CONGRATULATIONS!

You have successfully completed the
tutorial!!

Click HERE to view REFERENCES
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.
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Porth, C.M. (2005) Pathophysiology: concepts of altered health states (7th ed). Philadelphia, PA:
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Lymphedema Network.
Special Thanks To The Following
For Permission To Use Graphics!
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Bellisse.com
Bocaradiology.com
Cancerbackup.org
Knueppels.com
Lymphacare.com
Lymphnotes.com
Med-ars.it
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Vascularsociety.org
Special thanks to Ann
from lymphnotes.com
for sending wallet cards
and handouts and to my
preceptor, Julie Griffie,
for all of her support.