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

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

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

4 Objectives Understand/describe the normal structure and function of the lymphatic system. Understand/describe the normal structure and function of the lymphatic system. Identify risk factors affecting the normal drainage 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. Discuss diseases or procedures that could predispose a patient to lymphedema. Explain assessment of a patient with lymphedema. Explain assessment of a patient with lymphedema. Describe nursing interventions to promote lymphatic drainage for a patient with lymphedema. Describe nursing interventions to promote lymphatic drainage for a patient with lymphedema. Participate in a case study Participate in a case study

5 Table of Contents Choose a topic listed below to go to that section of the tutorial. Choose a topic listed below to go to that section of the tutorial. 1. Pathophysiology 2. Risk FactorsRisk Factors 4. Prevention andPrevention and Treatment 5. Nursing DiagnosesNursing Diagnoses6. Case StudyCase Study 3. DiagnosisDiagnosis

6 What is lymphedema? Lymphedema is an abnormal accumulation of high-protein concentrated fluid, usually in the arms and legs. Lymphedema is an abnormal accumulation of high-protein concentrated fluid, usually in the arms and legs. Dell & Doll, 2006 Dell & Doll, 2006 Image reproduced with permission from vascularsociety.org

7 The Lymphatics The lymphatic system filters and collects lymph and large molecules in the interstitial space that come from the intravascular space. The lymphatic system filters and collects lymph and large molecules in the interstitial space that come from the intravascular space. interstitial Golshan & Smith, 2006 Golshan & Smith, 2006 Used with permission from lymphacare.com

8 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. 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 Nazarko, 2006

9 This interstitial fluid contains proteins, lipids, water, and products from cellular breakdown. This interstitial fluid contains proteins, lipids, water, and products from cellular breakdown. Golshan & Smith, 2006 Golshan & Smith, 2006 Lymphatic vessels are similar to veins, but with thinner walls to allow larger proteins to permeate through. Lymphatic vessels are similar to veins, but with thinner walls to allow larger proteins to permeate through. Holcomb, 2006 Holcomb, 2006 National Cancer Institute, 2006 National Cancer Institute, 2006

10 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. 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.basement membranebasement membrane Golshan and Smith, 2006 Golshan and Smith, 2006 Used with permission by www.med-ars.it

11 Once this interstitial fluid is absorbed, it moves through the lymphatic vessels, and is considered lymph fluid. 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. 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 National Cancer Institute, 2006 Used with permission from Lymphnotes.com

12 The lymph system carries the lymphocytes throughout the body to respond to antigens and communicate responses to other parts of the body. The lymph system carries the lymphocytes throughout the body to respond to antigens and communicate responses to other parts of the body.lymphocytes Lacovara & Yoder, 2006 Lacovara & Yoder, 2006

13 Lymph then travels through multiple lymphatic channels and nodes before returning to the venous system by the thoracic duct. Lymph then travels through multiple lymphatic channels and nodes before returning to the venous system by the thoracic duct. Golshan and Smith, 2006 Golshan and Smith, 2006 Used with permission by med-ars.it

14 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. 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 Golshan and Smith, 2006 Used with permission from www.med-ars.it

15 Lymphedema occurs when there is an interruption or obstruction of the lymphatic system that causes an accumulation of fluid in the limb. 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 Golshan & Smith, 2006 Used with permission from lymphacare.com

16 A healthy adult has approximately 600-700 lymph nodes. A healthy adult has approximately 600-700 lymph nodes. Lacovara & Yoder, 2006 Lacovara & Yoder, 2006 The main areas are: The main areas are: Supraclavicular Supraclavicular Retroperitoneal (deep abdomen and pelvis) Retroperitoneal (deep abdomen and pelvis) Trachea Trachea Thoracic (adjacent to the lung) Thoracic (adjacent to the lung) Thiadens, 2005 Thiadens, 2005

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

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

19 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. On the trip back, the lymph fluid passes through lymph nodes, where it is cleaned and filtered The lymph fluid then enters either the thoracic duct or right lymphatic duct The fluid is then enters the subclavian veins and is returned to the circulatory system. Thoracic Duct www.lymphacare.com Mader, 1994

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

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

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

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

24 Risk Factor: Surgery Any surgery that dissects or removes lymph nodes increases the risk of lymphedema by impairing the lymph flow. Any surgery that dissects or removes lymph nodes increases the risk of lymphedema by impairing the lymph flow. Marrs, 2007; Lacovara & Yoder, 2006 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. 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 Thiadens, 2005

25 Risk Factor: Obstruction Tumors themselves may cause lymphedema by obstructing the lymphatic vessels. Tumors themselves may cause lymphedema by obstructing the lymphatic vessels. Dell & Doll, 2006 Dell & Doll, 2006 This is can be seen with cervical cancer, prostate cancer, or head and neck cancer. This is can be seen with cervical cancer, prostate cancer, or head and neck cancer. Nazarko, 2006; Romero, 2007. Nazarko, 2006; Romero, 2007.

26 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. 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 Golshan & Smith, 2006

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

28 The sentinel lymph node is the first lymph node draining from this tumor bed. The sentinel lymph node is the first lymph node draining from this tumor bed. Dow, 2002 Dow, 2002 Used with permission from www.med-ars.it Tumor Sentinel Node

29 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. 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 Dell, 2005 If the sentinel node is benign, no further lymph node removal is needed. If the sentinel node is benign, no further lymph node removal is needed. Thaidens, 2005 Thaidens, 2005

30 However if the sentinel node is positive, the axillary nodes may need to be removed, which increases the chances of lymphedema by 30-60%. 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 Golshan and Smith, 2006 Used with permission from Bocaradiology.org

31 Other Risks: Infection and Injury Things such as infections, bug bites, and bee stings may lead to lymphedema in a high-risk patient. 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. 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. 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 Dell & Doll, 2006

32 Other Possible Risks: Other causes that may lead to lymphedema include: Other causes that may lead to lymphedema include: Scarring from a vesicant extravasation Scarring from a vesicant extravasationextravasation Local burns Local burns Lymph node metastasis Lymph node metastasis Itano & Taoka, 2005 Itano & Taoka, 2005

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

34 Correct! Malignant Melanoma can lead to lymphedema. Here s how: 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. 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 Itano & Taoka, 2005 Possible risk areas: Axillary Nodes Inguinal Nodes www. cancebackup. org Click here to return to question

35 Right! Here s how: 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. 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. Inguinal Nodes www. cancebackup. org Click HERE to return to question

36 Correct! Head and Neck cancer Correct! Head and Neck cancer can cause lymphedema. can cause lymphedema. Here s how: Here s how: Squamous cell carcinoma occurring in the head and neck may obstruct lymph nodes or require removal of near by nodes. 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. A common treatment of head and neck cancer also includes radiation. Romero, 2007 Romero, 2007 Click HERE to return to question Click HERE to return to question Click HERE to return to question Click HERE to return to question

37 Right! Here s how colon cancer can lead to lymphedema: 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. Tumors can invade beyond the submucosal layer and have direct access to the lymphatic system. Itano & Taoka, 2005 Itano & Taoka, 2005 Treatment for colon cancer includes surgery and radiation, which may damage regional lymph nodes. Treatment for colon cancer includes surgery and radiation, which may damage regional lymph nodes. Click HERE to return to question Click HERE to return to question Click HERE to return to question Click HERE to return to question

38 Good! Let s look at how prostate and Good! Let s look at how prostate and bladder cancer can lead to lymphedema: bladder cancer can lead to lymphedema: In advanced bladder cancer, a cystectomy In advanced bladder cancer, a cystectomy may be performed, removing the bladder, may be performed, removing the bladder, prostate (men) and hysterectomy (women). prostate (men) and hysterectomy (women). Itano & Taoka, 2005 Itano & Taoka, 2005 Radiation is also a method of treatment for advanced stages, putting regional lymph nodes at risk. 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. This patient would be at risk for lower extremity lymphedema. Click HERE to return to question Click HERE to return to question Click HERE to return to question Click HERE to return to question

39 Yes! Sarcoma can lead to Yes! Sarcoma can lead to lymphedema. Here s how: lymphedema. Here s how: The goal of treatment for The goal of treatment for sarcoma is surgical removal. sarcoma is surgical removal. Itano & Taoka, 2005 Itano & Taoka, 2005 Depending on location, lymph nodes may be damaged of removed 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. Radiation may be used to reduce tumor size. This also puts lymph nodes at risk for fibrosis. Click HERE to return to question Click HERE to return to question Click HERE to return to question Click HERE to return to question

40 Diagnosing Lymphedema Painless swelling of the arms or legs, which may get worse during the day and better at night. Painless swelling of the arms or legs, which may 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, numbness, or weakness in the affected extremity. A feeling of tightness, heaviness, tingling, 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, 2006 Lacovara & Yoder, 2006

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

42 Infection Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Lacovora & Yoder, 2006 Lacovora & Yoder, 2006 Low prophylactic doses of antibiotics may be used if patients develop cellulitis frequently. Low prophylactic doses of antibiotics may be used if patients develop cellulitis frequently. Thiadens, 2005 Thiadens, 2005 Cellulitis: used with permission from www.med-ars.it

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

44 Stage II Considered irreversible Considered irreversible May be non-pitting and fibrotic May be non-pitting and fibrotic Elevation does not reduce swelling. Elevation does not reduce swelling. Lacovara and Yoder, 2006 Lacovara and Yoder, 2006 There is 3 to 5 cm difference between extremities. There is 3 to 5 cm difference between extremities. Itano & Taoka, 2005 Itano & Taoka, 2005 Used with permission from lymphacare.com

45 Stage III Tissues are hard and may have cartilage formation developing. Tissues are hard and may have cartilage formation developing. Swelling is severe and may form deep crevices. Swelling is severe and may form deep crevices. Lacovara and Yoder, 2006 Lacovara and Yoder, 2006 There is a > 5 cm difference between extremities. There is a > 5 cm difference between extremities. Itano & Taoka, 2005 Itano & Taoka, 2005 Photo Courtesy of Lymph Notes (www.lymphnotes.com )

46 Stage II Lymphedema is reversible TRUE TRUE TRUE Click on correct answer Click on correct answer FALSE

47 Correct! Stage II lymphedema is Correct! 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 treatment options! Continue on with the tutorial to learn about treatment options!

48 No, unfortunately Stage II lymphedema No, unfortunately Stage II lymphedema is not reversible. With treatment, it is possible is not reversible. With treatment, it is possible to minimize the effect. to minimize the effect. Continue with the tutorial to learn about treatment options! Continue with the tutorial to learn about treatment options! Click here to return to QUESTION Click here to return to QUESTION Click here to return to QUESTION Click here to return to QUESTION

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

50 The rationale is if any foreign object, such as a needle, is placed in the affected extremity, it will cause an inflammatory response. 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. This puts the lymphatic system under more stress, which may cause swelling to occur. Cole, 2006 Cole, 2006

51 Anything that may cause Anything that may cause pressure needs to be avoided, pressure needs to be avoided,including: Blood pressure cuffs Blood pressure cuffs Tourequets Tourequets Tight clothes (waist bands, bra straps, socks) Tight clothes (waist bands, bra straps, socks) This constricts collateral circulation This constricts collateral circulationcollateral circulationcollateral circulation Dell & Doll, 2006 Dell & Doll, 2006

52 Good skin care: Good skin care: Keep the skin clean and dry Keep the skin clean and dry Apply moisturizer daily Apply moisturizer daily Protect skin with sunscreen and insect repellant Protect skin with sunscreen and insect repellant Use care with razors Use care with razors Wear gloves when gardening, etc to protect the skin Wear gloves when gardening, etc to protect the skin Keep cuts clean and dry – monitor closely for S & S of infection Keep cuts clean and dry – monitor closely for S & S of infection Contact physician immediately for rash, redness, pain, increased swelling, etc. Contact physician immediately for rash, redness, pain, increased swelling, etc. Thiadens, 2005 Thiadens, 2005

53 Avoid extreme temperatures. 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. 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 Dell & Doll, 2006 Cold may cause rebound swelling or chapped skin Cold may cause rebound swelling or chapped skin Thiadens, 2005 Thiadens, 2005

54 Air travel > 2 hours increases the risk of swelling because of continuous reduction of cabin pressure. Air travel > 2 hours increases the risk of swelling because of continuous reduction of cabin pressure. Dell & Doll, 2006 Dell & Doll, 2006 It is recommended to wear a compression stocking while flying. It is recommended to wear a compression stocking while flying. Thiadens, 2005 Thiadens, 2005 Avoid carrying a purse, briefcase, or other heavy item with the affected extremity. 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. If the lower extremity is affected, avoid standing or sitting for long periods of time and do not cross legs. Marrs, 2007 Marrs, 2007

55 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. A. Have the patient carry a wallet card that identifies affected extremity. A. Have the patient carry a wallet card that identifies affected extremity. A. Have the patient carry a wallet card that identifies affected extremity. Use an ID bracelet or arm band to identify affected extremity. Use an ID bracelet or arm band to identify affected extremity. Use an ID bracelet or arm band to identify affected extremity. Use an ID bracelet or arm band to identify affected extremity. Tie a string around the affected extremity. Tie a string around the affected extremity. Tie a string around the affected extremity Tie a string around the affected extremity Click here to move to TREATMENT OPTIONS

56 Correct! Many patients carry wallet cards to remind themselves and healthcare provider of the affected extremity. Many patients carry wallet cards to remind themselves 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: Click here to return to question Click here to return to question Click here to return to question Click here to return to question Courtesy of www.lymphnotes.com

57 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. 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: Here is an example: Click here to return to question. Click here to return to question. Click here to return to question Click here to return to question

58 Incorrect 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 collateral circulation and cause lymphedema or make existing lymphedema worse! 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 Click here to return to question Click here to return to question Click here to return to question

59 Treatment Manual Lymph Drainage (MLD) Manual Lymph Drainage (MLD) Performed by specially trained therapist Performed by specially trained therapist Massaging connective tissue rather that deep muscles 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. 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. May also be taught to patient to perform on self. Thiadens, 2005; Dell & Doll, 2006 Thiadens, 2005; Dell & Doll, 2006 Used with permission by www.bellisse.com

60 Used with permission from lymphacare.com

61 Compression Bandaging Compression Bandaging Bandages may be applied to increase tissue pressure and counteract the elastic insufficiency of the connective tissue. Bandages may be applied to increase tissue pressure and counteract the elastic insufficiency of the connective tissue. Thiadens, 2005 Thiadens, 2005 Used with permission from lymphacare.com

62 Once a manageable size has been achieved from wrapping, a compression stocking may be worn to maintain the size and prevent increased swelling. 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 Thiadens, 2005 Used with permission By knueppels.com

63 There are no medications available at this time to treat lymphedema. 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. 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 Holcomb, 2006

64 Nursing Diagnosis Impaired physical mobility Impaired physical mobility Disturbed body image Disturbed body image Risk for infection Risk for infection Risk for impaired skin integrity Risk for impaired skin integrity Itano & Taoka, 2005 Itano & Taoka, 2005

65 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. 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.

66 How does this procedure put the patient at risk for lymphedema? (Click on the correct answers) A. There is minimal risk with this procedure. A. There is minimal risk with this procedure. 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, putting the patient at risk during this time. B. The lymphatic system needs time to heal itself, putting the patient at risk during this time. B. The lymphatic system needs time to heal itself, putting the patient at risk during this time. 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. C. This impairs the lymphatic flow in the axillary region, making her more susceptible to lymphedema in the right arm. C. This impairs the lymphatic flow in the axillary region, making her more susceptible to lymphedema in the right arm. C. This impairs the lymphatic flow in the axillary region, making her more susceptible to lymphedema in the right arm.

67 Incorrect Any time there is surgical removal of any lymph node, the patient is at risk for lymphedema. Any time there is surgical removal of any lymph node, the patient is at risk for lymphedema. Please try the question again! Please try the question again! Click here to return Click here to return Click here to return Click here to return

68 Incorrect The lymphatic system is not able to heal itself; therefore, the risk of lymphedema is always present. The lymphatic system is not able to heal itself; therefore, the risk of lymphedema is always present. Please try the question again! Please try the question again! Click here to return to the question Click here to return to the question Click here to return to the question Click here to return to the question

69 Correct! When the lymphatic flow is impaired or obstructed, the risk of lymphedema increases. When the lymphatic flow is impaired or obstructed, the risk of lymphedema increases. Area of concern Used with permission from cancerbackup.org Click here to go to the next question

70 How much is the patients risk for lymphedema increased due to axillary node involvement? (Click on the correct answer) A. No increase A. No increase A. No increase A. No increase B. 5% B. 5% B. 5% B. 5% C. 10 - 15% C. 10 - 15% C. 10 - 15% C. 10 - 15% D. 30 - 60% D. 30 - 60% D. 30 - 60% D. 30 - 60% Golshan & Smith, 2006 Golshan & Smith, 2006

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

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

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

74 Correct! The risk is 30-60%, which is pretty high! 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! This is why it is so important to educate your patients and fellow nurses on prevention! Click here to go to the next question. Click here to go to the next question. Click here to go to the next question. Click here to go to the next question.

75 Identify methods of prevention you will want to teach your patient: (Click on screen for answers) Good skin care Good skin care Clean and dry Clean and dry Moisturize Moisturize Use sunscreen Use sunscreen Use electric razors Use electric razors Wear gardening gloves Wear gardening gloves Keep cuts clean and dry Keep cuts clean and dry Contact MD for any S & S of infection 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

76 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 Swelling in the right arm only Any edema (pitting or non-pitting) Any edema (pitting or non-pitting) Watch for any redness and tight rings, watches, or bracelets. 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

77 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 A. MLD – Manual Lymphatic drainage A. MLD – Manual Lymphatic drainage A. MLD – Manual Lymphatic drainage B. Wrapping the extremity B. Wrapping the extremity B. Wrapping the extremity B. Wrapping the extremity C. Compression garment C. Compression garment C. Compression garment C. Compression garment Click HERE to go to next question

78 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. 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. It should be performed at least once a day for about 10-15 minutes. Academy of Lymphatic Studies, 2006 Academy of Lymphatic Studies, 2006 Used with permission by www.bellisse.com Click HERE to return to question

79 Correct! After MLD is performed, the extremity should be wrapped to reduce and soften fibrotic tissue. After MLD is performed, the extremity should be wrapped to reduce and soften fibrotic tissue. Academy of Lymphatic Studies, 2006 Academy of Lymphatic Studies, 2006 Used with permission from lymphacare.com Click HERE to return to question

80 Right! Once the extremity is a manageable size, a compression stocking should be worn to maintain this size. Once the extremity is a manageable size, a compression stocking should be worn to maintain this size. Thiadens, 2005 Thiadens, 2005 Used with permission By knueppels.com Click HERE to return to question

81 What are some possible nursing outcomes? (Click on all possible answers) A. Impaired physical mobility A. Impaired physical mobility A. Impaired physical mobility A. Impaired physical mobility B. Disturbed body image B. Disturbed body image B. Disturbed body image B. Disturbed body image C. Risk for infection C. Risk for infection C. Risk for infection C. Risk for infection D. Risk for impaired skin integrity D. Risk for impaired skin integrity D. Risk for impaired skin integrity D. Risk for impaired skin integrity Itano & Taoka, 2005 Itano & Taoka, 2005 Click HERE to END tutorial

82 Right! Lymphedema can make mobility difficult, especially lower extremity lymphedema. 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. It is important to assess your patient and refer to physical therapy for exercises and activity restrictions. Used with permission from lymphacare.com Click HERE to return to question

83 Correct! A patient with lymphedema may have a disturbed body image from such things as wearing over-sized clothes or two different sized shoes. 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. It is important to address these things with your patient. Click HERE to return to question

84 Yes! Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Lacovora & Yoder, 2006 Lacovora & Yoder, 2006 Low prophylactic doses of antibiotics may be used if patients develop cellulitis frequently. Low prophylactic doses of antibiotics may be used if patients develop cellulitis frequently. Thiadens, 2005 Thiadens, 2005 Cellulitis: used with permission from www.med-ars.it Click HERE to return to question

85 Correct! Skin on the affected arm may be more dry than normal. Skin on the affected arm may be more dry than normal. Academy of Lymphatic Studies, 2006 Academy of Lymphatic Studies, 2006 Good skin care is essential to prevent infection; wraps and compression stockings may retain moisture against the skin. Good skin care is essential to prevent infection; wraps and compression stockings may retain moisture against the skin. Click HERE to return to question

86 CONGRATULATIONS! You have successfully completed the tutorial!! You have successfully completed the tutorial!! Click HERE to view REFERENCES Click HERE to view REFERENCES Click HERE to view REFERENCES Click HERE to view REFERENCES

87 References Academy of Lymphatic Studies (2006 ) The source for research based lymphedema management. CD Rom. Sebastian, FL. ACOLS 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. 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. 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. (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. 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 (2 nd ed). Sudbury, MA: Jones and Bartlett Publishers. Dow, K.H. (2002). Pocket guide to breast cancer (2 nd 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 Golshan, M., Smith, B. (2006). Prevention and management of arm lymphedema in the patient with breast cancer. Supportive Oncology 4(8). pp. 381-386

88 Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Nursing Made Incredibly Easy! 4(2). Pp26-34. 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 (4 th ed) Philadelphia, PA: Elsevier Saunders. Itano, J.K., Taoka, K.N. (2005). Core curriculum for oncology nursing (4 th 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. 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: 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 (2 nd ed). Dubuque, IA: Wm. C. Brown Publishers. Mader, S. (1994). Understanding human anatomy and physiology (2 nd 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. 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 National Cancer Institute (2006). www.cancer.gov. retrieved 4/5/07www.cancer.gov Nazarko, L. (2006). Understanding lymphedema in older people. Nursing & Residential Care. 8 (6). Pp.254-258. Nazarko, L. (2006). Understanding lymphedema in older people. Nursing & Residential Care. 8 (6). Pp.254-258.

89 Porth, C.M. (2005) Pathophysiology: concepts of altered health states (7 th ed). Philadelphia, PA: Lippincott Williams & Wilkins. Porth, C.M. (2005) Pathophysiology: concepts of altered health states (7 th ed). Philadelphia, PA: Lippincott Williams & Wilkins. Romero, R. (2007). Bandaging options for head and neck edema. eLymphnotes. Retrieved from www.elymphnotes.org 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. (8 th ed). Oakland, CA: National Lymphedema Network. Thiadens, S.R.J., (2005). Lymphedema: an information booklet. (8 th ed). Oakland, CA: National Lymphedema Network.

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


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