1. Emily Richter, RN, BSN, OCN Alverno College Spring 2007
Lymphedema
Emily Richter, RN, BSN, OCN
Alverno College
Spring 2007
Click on arrow for next slide

2. Directions for Tutorial
Use the arrows at the bottom of the page to move about the tutorial.
This arrow moves you forward
This arrow takes you back one page
This button will take you back to the main menu
Table of Contents

3. Objectives
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

4. Table of Contents
Choose a topic listed below to go to that section of the tutorial.
2. Risk Factors
1. Pathophysiology
4. Prevention and
Treatment
3. Diagnosis
5. Nursing Diagnoses
6. Case Study

5. 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
Table of Contents

6. 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
Table of Contents

7. Normally, the heart pumps so strongly that it causes 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
Table of Contents
Table of Contents

8. 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.
Holcomb, 2006
National Cancer Institute, 2006
Table of Contents

9. 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
Table of Contents

10. 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
Table of Contents

11. 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
Table of Contents

12. 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
Table of Contents

13. 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
Table of Contents

14. 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
Table of Contents

15. 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
Table of Contents

16. Abdominal (near the intestine) Axilla The pelvic area Inguinal
Also found in tonsils,
spleen, intestinal wall,
and bone marrow.
Thiadens, 2005
Table of Contents

17. Identify Major Lymph Nodes Click on the body
Cervical Nodes
Spleen
Axillary Nodes
Inguinal Nodes
Used with permission from cancerbackup.org

18. 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
The fluid is then enters the
subclavian veins and is returned
to the circulatory system.

19. Why is the lymphatic system so important
Why is the lymphatic system so important? (Click on all correct answers)
A. The lymph system collects excess tissue fluid.
B. It plays a major role in the body’s defense against disease.
C. It circulates blood throughout the body
Table of Contents

20. Right!
The lymph system absorbs interstitial fluid and returns it back to the blood circulation.
Click here to return to question

21. Correct!
The lymph system circulates lymphocytes, such as T Cells, B Cells, and NK Cells.
Click here to return to question

22. Incorrect
This is a different system…. the lymphatic system contains fluid, not blood.
Click here to return to question

23. 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
Table of Contents

24. Risk Factor: Obstruction
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.
Table of Contents

25. Risk Factor: Radiation
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
Table of Contents

26. Risk Factor: Lymphedema and Breast Cancer
It is estimated that 15-20% of patients with breast cancer will experience lymphedema.
Lacova & Yoder, 2006
The tumor bed in the breast may drain into the lymphatics.
Dow, 2002
Table of Contents

27. The sentinel lymph node is the first lymph node draining from this tumor bed.
Dow, 2002
Sentinel Node
Tumor
Used with permission from
Table of Contents

28. 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
Table of Contents

29. 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
Table of Contents

30. 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
Table of Contents

31. Other Possible Risks:
Other causes that may lead to lymphedema include:
Scarring from a vesicant extravasation
Local burns
Lymph node metastasis
Itano & Taoka, 2005
Table of Contents

32. Review: What cancers can be associated with lymphedema?
Malignant Melanoma
Gynecological Cancers
Head and Neck
Colon
Prostate/Bladder
Sarcoma
Click on all of the correct answers
Table of Contents

33. 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.
Itano & Taoka, 2005
Click here
to return
to question
Possible risk areas:
www.
cancebackup.
org
Axillary Nodes
Inguinal Nodes

34. 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

35. 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.
Romero, 2007
Click HERE to return to question

36. 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.
Itano & Taoka, 2005
Treatment for colon cancer includes surgery and radiation, which may damage regional lymph nodes.
Click HERE to return to question

37. 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).
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

38. lymphedema. Here’s how:
Yes! Sarcoma can lead to
lymphedema. Here’s how:
The goal of treatment for
sarcoma is surgical removal.
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

39. Diagnosing Lymphedema
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
Table of Contents

40. Diagnosis, Continued…
A 2 cm difference between affected extremity and non-affected extremity is a general classification.
Bicego, et al, 2006
Tends to occur distal to proximal
Increased pigmentation/superficial veins
Secondary cellulitis
Itano & Taoka, 2005
Table of Contents

41. Infection
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
Table of Contents

42. Stages of Lymphedema: Stage I
Considered reversible
There is pitting and the tissue is soft
Arm girth may or may not be increased.
Treatment = elevation
Lacovara & Yodder,
2006
There is > 3 cm difference between extremities
Itano & Taoka, 2005
Used with permission from lymphacare.com
Table of Contents

43. 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
Table of Contents

44. 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 (
Table of Contents

45. Stage II Lymphedema is reversible
TRUE
Click on correct answer
FALSE

46. 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!
Table of Contents

47. Click here to return to QUESTION
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

48. Prevention
No blood draws, IVs, blood pressures, or injections should be taken on the affected extremity.
Thiadens, 2005
This includes all needle sticks, such as sub-q/IM injections and finger pricks for blood sugar testing.
Cole, 2006
Table of Contents

49. 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
Table of Contents

50. 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
Table of Contents

51. 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
Table of Contents

52. 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
Table of Contents

53. It is recommended to wear a compression stocking while flying.
Air travel > 2 hours increases the risk of swelling because of continuous reduction of cabin pressure.
Dell & Doll, 2006
It is recommended to wear a compression stocking while flying.
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
Table of Contents

54. What would be a good method to identify an effected/at risk extremity
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

55. 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:
Click here to return to question
Courtesy of

56. 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.

57. 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

58. Treatment Manual Lymph Drainage (MLD)
Used with permission by
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
Table of Contents

59. Used with permission from lymphacare.com
Table of Contents

60. 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
Table of Contents

61. 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
Table of Contents

62. 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
Table of Contents

63. Nursing Diagnosis Impaired physical mobility Disturbed body image
Risk for infection
Risk for impaired skin integrity
Itano & Taoka, 2005
Table of Contents

64. 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 axillary lymph nodes.
Table of Contents

65. How does this procedure put the patient at risk for lymphedema
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.
Table of Contents

66. 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

67. 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

68. Correct! Click here to go to the next question
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

69. How much is the patients risk for lymphedema increased due to axillary node involvement? (Click on the correct answer)
A. No increase
B. 5%
C %
D %
Golshan & Smith, 2006
Table of Contents

70. Nope!
Any time there is lymph node involvement, there is a risk of lymphedema
Try again!
Click here to return to the question

71. Incorrect 5% seems a bit low…. Please try again!
Click here to return to question.

72. Try Again 5-10% is not the correct answer. Please try again.
Click here to return to the question.

73. 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.

74. Identify methods of prevention you will want to teach your patient: (Click on screen for answers)
Avoid extreme temperatures
Encourage caution with air travel
Avoid carrying heavy things/extreme motions
No blood draws/IVs/BPs/finger sticks in R arm!!!
Good skin care
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
Click here to go to the next question

75. Click on screen for answers
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

76. You observe these signs and symptoms in her R arm
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

77. YES! Click HERE to return to question
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 minutes.
Academy of Lymphatic Studies, 2006
Used with permission by
Click HERE to return to question

78. 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

79. 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

80. What are some possible nursing outcomes
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
Table of Contents

81. 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

82. 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

83. 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
Click HERE to
return to question

84. 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

85. CONGRATULATIONS! You have successfully completed the tutorial!!
Click HERE to view REFERENCES
Table of Contents

86. References
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
Cole, T. (2006). Risks and benefits of needle use in patients after axillary node surgery. British Journal of Nursing 15(18) pp
Dell, D.D. (2005). Spread the word about breast cancer. Nursing (10). pp56-63
Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema. Nursing (6). pp
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
Table of Contents

87. Holcomb, S. S. (2006). Putting the squeeze on lymphedema. Nursing Made
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
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
National Cancer Institute (2006). retrieved 4/5/07
Nazarko, L. (2006). Understanding lymphedema in older people. Nursing & Residential Care. 8 (6). Pp
Table of Contents

88. 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
Thiadens, S.R.J., (2005). Lymphedema: an information booklet. (8th ed). Oakland, CA: National Lymphedema Network.
Table of Contents

89. Special Thanks To The Following For Permission To Use Graphics!
Bellisse.com
Bocaradiology.com
Cancerbackup.org
Knueppels.com
Lymphacare.com
Lymphnotes.com
Med-ars.it
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.
Table of Contents