Lymph Edema Tutorial

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

Alverno CollegeAlverno CollegeSpring 2007Spring 2007

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Directions for TutorialDirections for Tutorial Use the arrows at the bottom of the Use the arrows at the bottom of the

page to move about the tutorial.page to move about the tutorial. This arrow moves you forwardThis arrow moves you forward

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ObjectivesObjectives Understand/describe the normal structure and Understand/describe the normal structure and

function of the lymphatic system.function of the lymphatic system. Identify risk factors affecting the normal drainage Identify risk factors affecting the normal drainage

of the lymphatic system.of the lymphatic system. Discuss diseases or procedures that could Discuss diseases or procedures that could

predispose a patient to lymphedema.predispose a patient to lymphedema. Explain assessment of a patient with lymphedema.Explain assessment of a patient with lymphedema. Describe nursing interventions to promote Describe nursing interventions to promote

lymphatic drainage for a patient with lymphatic drainage for a patient with lymphedema.lymphedema.

Participate in a case studyParticipate in a case study

Table of ContentsTable of Contents Choose a topic listed below to go to Choose a topic listed below to go to

that section of the tutorial.that section of the tutorial.

1. Pathophysiology 2. Risk Factors

4. Prevention and Treatment

5. Nursing Diagnoses 6. Case Study

3. Diagnosis

What is lymphedema?What is lymphedema? Lymphedema is Lymphedema is

an abnormal an abnormal accumulation of accumulation of high-protein high-protein concentrated concentrated fluid, usually in fluid, usually in the arms and the arms and legs.legs.

Dell & Doll, 2006Dell & Doll, 2006Image reproduced with permission from vascularsociety.org

The LymphaticsThe Lymphatics The lymphatic The lymphatic

system filters and system filters and collects lymph collects lymph and large and large molecules in the molecules in the interstitialinterstitial space space that come from that come from the intravascular the intravascular space.space.

Golshan & Smith, Golshan & Smith, 20062006 Used with permission from lymphacare.com

Normally, the heart pumps so Normally, the heart pumps so strongly that it causes 20-30 liters of strongly that it causes 20-30 liters of plasma per day to leak from the plasma per day to leak from the capillaries. This is the capillaries. This is the interstitialinterstitial fluid, which the lymphatic system fluid, which the lymphatic system drains, filters, and returns to the drains, filters, and returns to the heart.heart.

Nazarko, 2006Nazarko, 2006

This This interstitialinterstitial fluid contains proteins, fluid contains proteins, lipids, water, and products from lipids, water, and products from cellular breakdown. cellular breakdown.

Golshan & Smith, 2006Golshan & Smith, 2006

Lymphatic vessels are similar to veins, Lymphatic vessels are similar to veins, but with thinner walls to allow larger but with thinner walls to allow larger proteins to permeate through.proteins to permeate through.

Holcomb, 2006Holcomb, 2006 National Cancer Institute, 2006National Cancer Institute, 2006

Lymph vessels usually do not have a large Lymph vessels usually do not have a large basement membranebasement membrane, which allows large , which allows large molecules to enter that cannot be molecules to enter that cannot be reabsorbed readily by the venous system. reabsorbed readily by the venous system.

Golshan and Smith, 2006Golshan and Smith, 2006

Used with permission by www.med-ars.it

Once this Once this interstitial interstitial fluid is absorbed, it fluid is absorbed, it moves through the moves through the lymphatic vessels, and is lymphatic vessels, and is considered lymph fluid.considered lymph fluid.

As lymph fluid moves As lymph fluid moves through the lymphatic through the lymphatic system, it passes system, it passes through through lymph nodes.lymph nodes. Lymph nodes filter Lymph nodes filter harmful substances and harmful substances and contain lymphocytes contain lymphocytes that activate the that activate the immune system.immune system.

National Cancer Institute, National Cancer Institute, 20062006 Used with permission from

Lymphnotes.com

The lymph system carries the The lymph system carries the lymphocyteslymphocytes throughout the body to throughout the body to respond to antigens and respond to antigens and communicate responses to other communicate responses to other parts of the body.parts of the body.

Lacovara & Yoder, 2006Lacovara & Yoder, 2006

Lymph then travels through multiple Lymph then travels through multiple lymphatic channels and nodes before lymphatic channels and nodes before returning to the venous system by the returning to the venous system by the thoracic duct.thoracic duct.

Golshan and Smith, 2006Golshan and Smith, 2006

Used with permission by med-ars.it

Under normal Under normal conditions, the conditions, the entry of fluid and entry of fluid and other materials into other materials into the interstitial the interstitial space is balanced space is balanced by outflow of the by outflow of the lymphatic fluid lymphatic fluid from the limb, from the limb, which maintains which maintains standard volume.standard volume.

Golshan and Smith, Golshan and Smith, 20062006

Used with permissionfrom www.med-ars.it

Lymphedema occurs when there is an Lymphedema occurs when there is an interruption or obstruction of the interruption or obstruction of the lymphatic system that causes an lymphatic system that causes an accumulation of fluid in the limb.accumulation of fluid in the limb.


Used with permission from lymphacare.com

A healthy adult has approximately A healthy adult has approximately 600-700 lymph nodes.600-700 lymph nodes.


The main areas are:The main areas are: Supraclavicular Supraclavicular Retroperitoneal (deep abdomen and Retroperitoneal (deep abdomen and

pelvis)pelvis) Trachea Trachea Thoracic (adjacent to the lung)Thoracic (adjacent to the lung)

Thiadens, 2005Thiadens, 2005

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


Identify Major Lymph Identify Major Lymph NodesNodes

Click on the bodyClick on the body

Used with permission from cancerbackup.org

Spleen

Inguinal Nodes

Cervical Nodes

Axillary Nodes

Review of the “Flow”Review of the “Flow”Click on the screenClick on the screen

Interstitial fluid has diffused from blood

capillaries

The lymph capillariesabsorb this interstitial

fluid

The capillaries jointo form vessels that

carry the lymph fluidback to the heart.

On the trip back, the lymph fluid passes

through lymph nodes,where it is cleaned and

filtered

The lymph fluid thenenters 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

Why is the lymphatic Why is the lymphatic system so important?system so important?(Click on all correct answers)(Click on all correct answers)

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

B. It plays a major role in the body’sB. It plays a major role in the body’s defense against disease. defense against disease.

C. It circulates blood throughout the C. It circulates blood throughout the bodybody

Right!Right! The lymph system absorbs The lymph system absorbs

interstitial fluid and returns it interstitial fluid and returns it back to the blood circulation.back to the blood circulation.

Click here to return to questionClick here to return to question

Correct!Correct! The lymph system circulates The lymph system circulates

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


IncorrectIncorrect

This is a different system…. the This is a different system…. the lymphatic system contains fluid, not lymphatic system contains fluid, not blood.blood.


Risk Factor: SurgeryRisk Factor: Surgery Any surgery that dissects or removes Any surgery that dissects or removes

lymph nodes increases the risk of lymph nodes increases the risk of lymphedema by impairing the lymph flow.lymphedema by impairing the lymph flow.

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

Common cancers that may require Common cancers that may require surgical alterations of the lymph nodes surgical alterations of the lymph nodes include breast cancer, melanoma, include breast cancer, melanoma, gynecological cancers, head and neck, gynecological cancers, head and neck, prostate, testicular, bladder, or colon prostate, testicular, bladder, or colon cancer. cancer.


Risk Factor: ObstructionRisk Factor: Obstruction Tumors themselves may cause Tumors themselves may cause

lymphedema by obstructing the lymphedema by obstructing the lymphatic vessels.lymphatic vessels.

Dell & Doll, 2006Dell & Doll, 2006

This is can be seen with cervical This is can be seen with cervical cancer, prostate cancer, or head and cancer, prostate cancer, or head and neck cancer.neck cancer.

Nazarko, 2006; Romero, 2007.Nazarko, 2006; Romero, 2007.

Risk Factor: RadiationRisk Factor: Radiation Radiation therapy to Radiation therapy to

the axillary or groin the axillary or groin region around the region around the lymph node can cause lymph node can cause fibrosis and scarring fibrosis and scarring of the tissue and of the tissue and therefore cause therefore cause lymphedema to occur.lymphedema to occur.


Risk Factor: Risk Factor: Lymphedema and Lymphedema and

Breast CancerBreast Cancer It is estimated that 15-20% of It is estimated that 15-20% of

patients with breast cancer will patients with breast cancer will experience lymphedema.experience lymphedema.

Lacova & Yoder, 2006Lacova & Yoder, 2006

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

Dow, 2002Dow, 2002

The sentinel lymph node is the first The sentinel lymph node is the first lymph node draining from this tumor lymph node draining from this tumor bed.bed.

Dow, 2002Dow, 2002

Used with permission from www.med-ars.it

Tumor Sentinel Node

A technique called Sentinel Node A technique called Sentinel Node Biopsy can be performed, which the Biopsy can be performed, which the surgeon finds and removes this first surgeon finds and removes this first node and sends it for a pathologic node and sends it for a pathologic examination.examination.

Dell, 2005Dell, 2005

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

Thaidens, 2005Thaidens, 2005

However if the However if the sentinel node is sentinel node is positive, the positive, the axillary nodes axillary nodes may need to be may need to be removed, which removed, which increases the increases the chances of chances of lymphedema by lymphedema by 30-60%.30-60%.

Golshan and Smith, Golshan and Smith, 20062006

Used with permission from Bocaradiology.org

Other Risks: Infection Other Risks: Infection and Injuryand Injury

Things such as infections, bug bites, Things such as infections, bug bites, and bee stings may lead to and bee stings may lead to lymphedema in a high-risk patient.lymphedema in a high-risk patient.

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

to the affected site, however there is an to the affected site, however there is an obstruction or defect in the lymphatic obstruction or defect in the lymphatic system, causing lymph fluid to leak.system, causing lymph fluid to leak.


Other Possible Risks:Other Possible Risks: Other causes that may lead to Other causes that may lead to

lymphedema include:lymphedema include: Scarring from a vesicant Scarring from a vesicant extravasationextravasation Local burnsLocal burns Lymph node metastasisLymph node metastasis

Itano & Taoka, 2005Itano & Taoka, 2005

Review: What cancers can Review: What cancers can be associated with be associated with

lymphedema?lymphedema? Malignant MelaMalignant Mela

nomanoma Gynecological CGynecological C

ancersancers Head and NeckHead and Neck

ColonColon Prostate/BladderProstate/Bladder SarcomaSarcoma

Click on all of the correct answers

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

Malignant melanoma can metastasize to Malignant melanoma can metastasize to regional lymph nodes. Treatment for regional lymph nodes. Treatment for malignant melanoma may involve malignant melanoma may involve surgical resection; depending on location surgical resection; depending on location and extent of disease, the lymph nodes and extent of disease, the lymph nodes may need to be removed.may need to be removed.


Possible risk areas:Axillary Nodes

Inguinal Nodes

www.cancebackup.org

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Right! Here’s how:Right! Here’s how: When you think of gynecologic cancers When you think of gynecologic cancers

(ovarian, uterine, cervical), think location. (ovarian, uterine, cervical), think location. Surgical removal of the inguinal lymph Surgical removal of the inguinal lymph nodes puts the patient at risk for lower nodes puts the patient at risk for lower extremity lymphedema.extremity lymphedema.

Inguinal Nodes

www.cancebackup.org

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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 Squamous cell carcinoma occurring in the

head and neck may obstruct lymph nodes head and neck may obstruct lymph nodes or require removal of near by nodes.or require removal of near by nodes.

A common treatment of head and neck A common treatment of head and neck cancer also includes radiation.cancer also includes radiation.

Romero, 2007Romero, 2007

Click HERE to return to questionClick HERE to return to question

Right! Here’s how colon cancer can lead Right! Here’s how colon cancer can lead to lymphedema:to lymphedema:

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

Itano & Taoka, 2005 Itano & Taoka, 2005 Treatment for colon cancer includes Treatment for colon cancer includes

surgery and radiation, which may surgery and radiation, which may damage regional lymph nodes.damage regional lymph nodes.


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, 2005Itano & Taoka, 2005 Radiation is also a method of treatment for Radiation is also a method of treatment for

advanced stages, putting regional lymph advanced stages, putting regional lymph nodes at risk. nodes at risk.

This patient would be at risk for lower This patient would be at risk for lower extremity lymphedema.extremity lymphedema.


Yes! Sarcoma can lead to Yes! Sarcoma can lead to lymphedema. Here’s how:lymphedema. Here’s how:

The goal of treatment forThe goal of treatment for sarcoma is surgical removal.sarcoma is surgical removal.


Depending on location, lymph nodes may be Depending on location, lymph nodes may be damaged of removeddamaged of removed

Radiation may be used to reduce tumor size. Radiation may be used to reduce tumor size. This also puts lymph nodes at risk for This also puts lymph nodes at risk for fibrosis. fibrosis.


Diagnosing LymphedemaDiagnosing Lymphedema Painless swelling of the arms or legs, which Painless swelling of the arms or legs, which

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

Warmth or achiness in the extremity.Warmth or achiness in the extremity. A feeling of tightness, heaviness, tingling, A feeling of tightness, heaviness, tingling,

numbness, or weakness in the affected numbness, or weakness in the affected extremity.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.


Diagnosis, Continued…Diagnosis, Continued… A 2 cm difference between affected A 2 cm difference between affected

extremity and non-affected extremity extremity and non-affected extremity is a general classification.is a general classification.

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

Tends to occur distal to proximalTends to occur distal to proximal Increased pigmentation/superficial Increased pigmentation/superficial

veinsveins Secondary cellulitisSecondary cellulitis


InfectionInfection Infection may be common in Infection may be common in

lymphedema; pooling of protein-rich lymphedema; pooling of protein-rich lymph fluid increases cellulitis. lymph fluid increases cellulitis.

Lacovora & Yoder, 2006Lacovora & Yoder, 2006

Low prophylactic doses of antibiotics Low prophylactic doses of antibiotics may be used if patients develop may be used if patients develop cellulitis frequently. cellulitis frequently.

Thiadens, 2005Thiadens, 2005 Cellulitis: used withpermission fromwww.med-ars.it

Stages of Lymphedema:Stages of Lymphedema:Stage IStage I

Considered reversibleConsidered reversible There is pitting and There is pitting and

the tissue is softthe tissue is soft Arm girth may or may Arm girth may or may

not be increased.not be increased. Treatment = elevationTreatment = elevation

Lacovara & Yodder, Lacovara & Yodder, 20062006

There is > 3 cm There is > 3 cm difference between difference between extremitiesextremities



Stage IIStage II Considered irreversibleConsidered irreversible May be non-pitting and fibroticMay be non-pitting and fibrotic Elevation does not reduce swelling.Elevation does not reduce swelling.

Lacovara and Yoder, 2006Lacovara and Yoder, 2006

There is 3 to 5 cm difference There is 3 to 5 cm difference between extremities.between extremities.

Itano & Taoka, 2005Itano & Taoka, 2005 Used with permission from lymphacare.com

Stage IIIStage III Tissues are hard and may have cartilage Tissues are hard and may have cartilage

formation developing.formation developing. Swelling is severe and may form deep Swelling is severe and may form deep

crevices.crevices. Lacovara and Yoder, 2006Lacovara and Yoder, 2006

There is a > 5 cm difference between There is a > 5 cm difference between extremities.extremities.


Photo Courtesy of Lymph Notes

(www.lymphnotes.com)

Stage II Lymphedema is Stage II Lymphedema is reversiblereversible

TRUETRUE

Click on correct Click on correct answeranswer

FALSEFALSE

Correct! Stage II lymphedema isCorrect! Stage II lymphedema is not reversible. With treatment, not reversible. With treatment, lymphedema may be minimized, lymphedema may be minimized, but it is never truly “cured”.but it is never truly “cured”. Continue on with the tutorial to learn Continue on with the tutorial to learn

about treatment options!about treatment options!

No, unfortunately Stage II lymphedema No, unfortunately Stage II lymphedema is not reversible. With treatment, it is is not reversible. With treatment, it is

possible possible to minimize the effect. to minimize the effect. Continue with the tutorial to learn about Continue with the tutorial to learn about

treatment options!treatment options!

Click here to return to QUESTIONClick here to return to QUESTION

PreventionPrevention No blood draws, IVs, blood No blood draws, IVs, blood

pressures, or injections should be pressures, or injections should be taken on the affected extremity.taken on the affected extremity.


This includes all needle sticks, such as This includes all needle sticks, such as sub-q/IM injections and finger pricks for sub-q/IM injections and finger pricks for blood sugar testing.blood sugar testing.

Cole, 2006Cole, 2006

The rationale is if any foreign The rationale is if any foreign object, such as a needle, is placed object, such as a needle, is placed in the affected extremity, it will in the affected extremity, it will cause an inflammatory response.cause an inflammatory response.

This puts the lymphatic system This puts the lymphatic system under more stress, which may under more stress, which may cause swelling to occur.cause swelling to occur.

Cole, 2006Cole, 2006

Anything that may cause Anything that may cause pressure needs to be avoided, pressure needs to be avoided,

including:including: Blood pressure cuffsBlood pressure cuffs TourequetsTourequets Tight clothes (waist bands, bra straps, Tight clothes (waist bands, bra straps,

socks)socks)

This constricts This constricts collateral circulationcollateral circulation Dell & Doll, 2006Dell & Doll, 2006

Good skin care:Good skin care: Keep the skin clean and dryKeep the skin clean and dry Apply moisturizer daily Apply moisturizer daily Protect skin with sunscreen and insect Protect skin with sunscreen and insect

repellantrepellant Use care with razorsUse care with razors Wear gloves when gardening, etc to protect Wear gloves when gardening, etc to protect

the skinthe skin Keep cuts clean and dry – monitor closely for Keep cuts clean and dry – monitor closely for

S & S of infectionS & S of infection Contact physician immediately for rash, Contact physician immediately for rash,

redness, pain, increased swelling, etc.redness, pain, increased swelling, etc. Thiadens, 2005Thiadens, 2005

Avoid extreme temperatures. Avoid extreme temperatures. Heat may cause vasodilatation, which Heat may cause vasodilatation, which

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


Cold may cause rebound swelling or Cold may cause rebound swelling or chapped skinchapped skin


Air travel > 2 hours increases the risk of Air travel > 2 hours increases the risk of swelling because of continuous reduction of swelling because of continuous reduction of cabin pressure.cabin pressure.


It is recommended to wear a compression It is recommended to wear a compression stocking while flying.stocking while flying.


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

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

Marrs, 2007Marrs, 2007

What would be a good What would be a good method to identify an method to identify an

effected/at risk extremity?effected/at risk extremity?(Click on all of the correct answers)(Click on all of the correct answers)

A. Have the patient carry a wallet cA. Have the patient carry a wallet card that identifies affected extremityard that identifies affected extremity..

Use an ID bracelet or arm band to idUse an ID bracelet or arm band to identify affected extremity.entify affected extremity.

Tie a string around the affected extrTie a string around the affected extremityemity.. Click here to move to

TREATMENT OPTIONS

Correct!Correct! Many patients carry wallet cards to remind Many patients carry wallet cards to remind

themselves and healthcare provider of the themselves and healthcare provider of the affected extremity.affected extremity.

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


Courtesy ofwww.lymphnotes.com

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

affected extremity to alert healthcare affected extremity to alert healthcare providers to avoid venipunctures, blood providers to avoid venipunctures, blood pressures, and fingersticks on this pressures, and fingersticks on this extremity.extremity.

Here is an example:Here is an example:

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

IncorrectIncorrect This is not an effective method of This is not an effective method of

identification.identification. If the string is too tight, it may constrict If the string is too tight, it may constrict

collateral circulation and cause collateral circulation and cause lymphedema or make existing lymphedema or make existing lymphedema worse!lymphedema worse!


TreatmenTreatmentt

Manual Lymph Drainage (MLD)Manual Lymph Drainage (MLD) Performed by specially trained therapist Performed by specially trained therapist Massaging connective tissue rather that deep Massaging connective tissue rather that deep

musclesmuscles Stimulates the weakened lymphatic system and Stimulates the weakened lymphatic system and

decongests the affected area to encourage decongests the affected area to encourage formation of new pathways to unimpaired formation of new pathways to unimpaired lymph nodes to reduce swelling.lymph nodes to reduce swelling.

May also be taught to patient to perform on May also be taught to patient to perform on self.self.

Thiadens, 2005; Dell & Doll, 2006Thiadens, 2005; Dell & Doll, 2006

Used with permission by www.bellisse.com


Compression BandagingCompression Bandaging Bandages may be applied to increase Bandages may be applied to increase

tissue pressure and counteract the tissue pressure and counteract the elastic insufficiency of the connective elastic insufficiency of the connective tissue.tissue.



Once a manageable size has been Once a manageable size has been achieved from wrapping, a achieved from wrapping, a compression stocking may be worn compression stocking may be worn to maintain the size and prevent to maintain the size and prevent increased swelling.increased swelling.


Used with permission By knueppels.com

There are no medications available at There are no medications available at this time to treat lymphedema.this time to treat lymphedema.

Diuretics should not be used to help Diuretics should not be used to help lymphedema because they draw off lymphedema because they draw off excess water in the interstitial excess water in the interstitial spaces, not the excess protein. Once spaces, not the excess protein. Once the diuretic is out of the system, it the diuretic is out of the system, it pulls more water into the affected pulls more water into the affected areaarea..

Holcomb, 2006Holcomb, 2006

Nursing DiagnosisNursing Diagnosis Impaired physical mobilityImpaired physical mobility Disturbed body imageDisturbed body image Risk for infectionRisk for infection Risk for impaired skin integrityRisk for impaired skin integrity


Case Study:Case Study: A 49 year-old woman diagnosed with A 49 year-old woman diagnosed with

infiltrating or invasive ductal carcinoma infiltrating or invasive ductal carcinoma of the right breast is scheduled for a of the right breast is scheduled for a mastectomy. To test the lymph node mastectomy. To test the lymph node involvement, a sentinel node biopsy is involvement, a sentinel node biopsy is performed, showing positive performed, showing positive involvement. A modified radical involvement. A modified radical mastectomy is then performed, removing mastectomy is then performed, removing all breast tissue and 15-20 axillary lymph all breast tissue and 15-20 axillary lymph nodes. nodes.

How does this procedure How does this procedure put the patient at risk for put the patient at risk for

lymphedema?lymphedema?(Click on the correct answers)(Click on the correct answers)

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

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

C. This impairs the lymphatic flow in tC. This impairs the lymphatic flow in the axillary region, making her more she axillary region, making her more susceptible to lymphedema in the rightusceptible to lymphedema in the right arm. arm.

IncorrectIncorrect Any time there is surgical removal of Any time there is surgical removal of

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

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

Click here to returnClick here to return

IncorrectIncorrect The lymphatic system is not able to The lymphatic system is not able to

heal itself; therefore, the risk of heal itself; therefore, the risk of lymphedema is always present.lymphedema is always present.

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

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

Correct!Correct! When the lymphatic flow is impaired or When the lymphatic flow is impaired or

obstructed, the risk of lymphedema obstructed, the risk of lymphedema increases.increases.

Area of concern

Used with permission from cancerbackup.org

Click here to go to the nextquestion

How much is the patients How much is the patients risk for lymphedema risk for lymphedema

increased due to axillary increased due to axillary node involvement?node involvement?

(Click on the correct answer)(Click on the correct answer) A. No increaseA. No increase B. 5%B. 5% C. 10 - 15%C. 10 - 15% D. 30 - 60%D. 30 - 60%


Nope!Nope! Any time there is lymph node Any time there is lymph node

involvement, there is a risk of involvement, there is a risk of lymphedemalymphedema

Try again!Try again!

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

IncorrectIncorrect

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.

Try AgainTry 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.

Correct!Correct!

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

This is why it is so important to This is why it is so important to educate your patients and fellow educate your patients and fellow nurses on prevention!nurses on prevention!

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

Identify methods of Identify methods of prevention you will want to prevention you will want to

teach your patient:teach your patient:(Click on screen for answers)(Click on screen for answers)

Good skin careGood skin care Clean and dryClean and dry MoisturizeMoisturize Use sunscreenUse sunscreen Use electric razorsUse electric razors Wear gardening Wear gardening

glovesgloves Keep cuts clean and Keep cuts clean and

drydry Contact MD for any S Contact MD for any S

& S of infection& S of infection

Avoid extreme Avoid extreme temperaturestemperatures

Encourage caution Encourage caution with air travelwith air travel

Avoid carrying heavy Avoid carrying heavy things/extreme things/extreme motionsmotions

No blood No blood draws/IVs/BPs/finger draws/IVs/BPs/finger sticks in R arm!!!sticks in R arm!!!

Click here to go to the next question

After receiving chemotherapy, she After receiving chemotherapy, she is admitted for a neutropenic is admitted for a neutropenic fever. When doing a physical fever. When doing a physical

assessment, what things should assessment, what things should you be watching for with her right you be watching for with her right

arm?arm? Swelling in the right Swelling in the right

arm onlyarm only Any edema (pitting or Any edema (pitting or

non-pitting)non-pitting) Watch for any Watch for any

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

A feeling of A feeling of heaviness, heaviness, achiness, tingling, achiness, tingling, numbness, or numbness, or weakness in the R weakness in the R arm reported by arm reported by the patient.the patient.

Click on screen for answers

Click HERE to go to the next question

You observe these signs and You observe these signs and symptoms in her R arm. symptoms in her R arm. What are her treatment What are her treatment

options?options?(Click on all correct answers)(Click on all correct answers)

A. MLD – Manual Lymphatic drainagA. MLD – Manual Lymphatic drainagee

B. Wrapping the extremityB. Wrapping the extremity

C. Compression garmentC. Compression garmentClick HERE to go to next question

YES!YES! MLD – Manual lymph MLD – Manual lymph

drainage is a gentle drainage is a gentle massage performed massage performed in the affected area to in the affected area to help move the lymph help move the lymph fluid back in the fluid back in the appropriate direction.appropriate direction.

It should be It should be performed at least performed at least once a day for about once a day for about 10-15 minutes.10-15 minutes.

Academy of Academy of Lymphatic Studies, Lymphatic Studies, 2006 2006

Used with permission by www.bellisse.com

Click HERE to return to question

Correct!Correct! After MLD is After MLD is

performed, the performed, the extremity should extremity should be wrapped to be wrapped to reduce and reduce and soften fibrotic soften fibrotic tissue.tissue.

Academy of Academy of Lymphatic Lymphatic Studies, 2006Studies, 2006



Right!Right! Once the Once the

extremity is a extremity is a manageable size, manageable size, a compression a compression stocking should be stocking should be worn to maintain worn to maintain this size.this size.


Used with permission By knueppels.com


What are some possible What are some possible nursing outcomes?nursing outcomes?(Click on all possible answers)(Click on all possible answers)

A. Impaired physical mobilityA. Impaired physical mobility B. Disturbed body imageB. Disturbed body image C. Risk for infectionC. Risk for infection D. Risk for impaired skin integrityD. Risk for impaired skin integrity


Click HERE to END tutorial

Right!Right! Lymphedema can make mobility Lymphedema can make mobility

difficult, especially lower extremity difficult, especially lower extremity lymphedema. lymphedema.

It is important to assess your patient It is important to assess your patient and refer to physical therapy for and refer to physical therapy for exercises and activity restrictions.exercises and activity restrictions.



Correct!Correct! A patient with lymphedema may have A patient with lymphedema may have

a disturbed body image from such a disturbed body image from such things as wearing over-sized clothes things as wearing over-sized clothes or two different sized shoes. or two different sized shoes.

It is important to address these It is important to address these things with your patient.things with your patient.


Yes!Yes! Infection may be Infection may be

common in common in lymphedema; pooling lymphedema; pooling of protein-rich lymph of protein-rich lymph fluid increases fluid increases cellulitis. cellulitis.

Lacovora & Yoder, 2006Lacovora & Yoder, 2006

Low prophylactic doses of Low prophylactic doses of antibiotics may be used if antibiotics may be used if patients develop cellulitis patients develop cellulitis frequently. frequently.


Cellulitis: used withpermission fromwww.med-ars.it


Correct!Correct! Skin on the affected arm may be Skin on the affected arm may be

more dry than normalmore dry than normal.. Academy of Lymphatic Studies, 2006Academy of Lymphatic Studies, 2006

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


CONGRATULATIONS!CONGRATULATIONS! You have successfully completed You have successfully completed

the tutorial!!the tutorial!!

Click HERE to view REFERENCESClick HERE to view REFERENCES

ReferencesReferences Academy of Lymphatic Studies (2006 ) The source for research based Academy of Lymphatic Studies (2006 ) The source for research based

lymphedema management. CD Rom. Sebastian, FL. ACOLSlymphedema management. CD Rom. Sebastian, FL. ACOLS Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R. Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., Harris, S.R.

(2006). (2006). Exercise for women with or at risk for breast cancer-Exercise for women with or at risk for breast cancer-related lymphedema. related lymphedema. Physical Therapy.Physical Therapy. 86 (10). pp. 1398- 86 (10). pp. 1398-1405.1405.

Cole, T. (2006). Risks and benefits of needle use in patients after Cole, T. (2006). Risks and benefits of needle use in patients after axillary node axillary node surgery. surgery. British Journal of Nursing British Journal of Nursing 15(18) pp. 969-15(18) pp. 969-979.979.

Dell, D.D. (2005). Spread the word about breast cancer. Dell, D.D. (2005). Spread the word about breast cancer. Nursing2005Nursing2005 35(10). 35(10). pp56-63pp56-63

Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema. Dell, D.D., Doll, C. (2006). Caring for a patient with lymphedema. Nursing2006.Nursing2006. 36(6). pp. 49-51.36(6). pp. 49-51.

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

Golshan, M., Smith, B. (2006). Prevention and management of arm Golshan, M., Smith, B. (2006). Prevention and management of arm lymphedema in the patient with breast cancer. lymphedema in the patient with breast cancer. Supportive Supportive

Oncology Oncology 4(8). pp. 4(8). pp. 381-386381-386

Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Holcomb, S.S. (2006). Putting the squeeze on lymphedema. Nursing Made Nursing Made Incredibly Easy! Incredibly Easy! 4(2). Pp26-34.4(2). Pp26-34.

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

Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the Lacovara, J.E., Yoder, L.H. (2006). Secondary lymphedema in the cancer patient. cancer patient. MEDSURG Nursing.MEDSURG Nursing. 15(5). pp. 302-306. 15(5). pp. 302-306.

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

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

Marrs, J. (2007). Lymphedema and implications for oncology Marrs, J. (2007). Lymphedema and implications for oncology nursing practice. nursing practice. Clinical Journal of Oncology Nursing.Clinical Journal of Oncology Nursing. 11(1). pp. 11(1). pp. 19-21.19-21.

National Cancer Institute (2006). National Cancer Institute (2006). www.cancer.govwww.cancer.gov. . retrieved retrieved 4/5/074/5/07

Nazarko, L. (2006). Understanding lymphedema in older people. Nazarko, L. (2006). Understanding lymphedema in older people. Nursing & Nursing & Residential Care.Residential Care. 8 (6). Pp.254-258. 8 (6). Pp.254-258.

http://www.cancer.gov/

Porth, C.M. (2005) Porth, C.M. (2005) Pathophysiology: concepts of altered health Pathophysiology: concepts of altered health statesstates (7 (7thth ed). Philadelphia, PA: ed). Philadelphia, PA: Lippincott Williams & Lippincott Williams & Wilkins.Wilkins.

Romero, R. (2007). Bandaging options for head and neck edema. Romero, R. (2007). Bandaging options for head and neck edema. eLymphnotes.eLymphnotes. Retrieved Retrieved from www.elymphnotes.orgfrom www.elymphnotes.org

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

Special Thanks To The Special Thanks To The Following For Permission Following For Permission

To Use Graphics!To Use Graphics! Bellisse.comBellisse.com Bocaradiology.comBocaradiology.com Cancerbackup.orgCancerbackup.org Knueppels.comKnueppels.com Lymphacare.comLymphacare.com Lymphnotes.comLymphnotes.com Med-ars.itMed-ars.it

Vascularsociety.orgVascularsociety.org Special thanks to Special thanks to

Ann from Ann from lymphnotes.com for lymphnotes.com for sending wallet cards sending wallet cards and handouts and to and handouts and to my preceptor, Julie my preceptor, Julie Griffie, for all of her Griffie, for all of her support.support.

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Lymph Edema Tutorial