Lymphedema

1
Lymphedema

• Emily Richter, RN, BSN, OCN
• Alverno College
• Spring 2007

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Directions for Tutorial

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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

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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
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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
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• Normally, the heart pumps so strongly that it
  causes 20-30 liters of plasma per day to leak
  from the capillaries. This is the interstitial
  fluid, which the lymphatic system drains,
  filters, and returns to the heart.
• Nazarko, 2006

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

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• Lymph vessels usually do not have a large
  basement membrane, which allows large molecules
  to enter that cannot be reabsorbed readily by the
  venous system.
• Golshan and Smith, 2006

Used with permission by www.med-ars.it
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• Once this interstitial fluid is absorbed, it
  moves through the lymphatic vessels, and is
  considered lymph fluid.
• As lymph fluid moves through the lymphatic
  system, it passes through lymph nodes. Lymph
  nodes filter harmful substances and contain
  lymphocytes that activate the immune system.
• National Cancer Institute, 2006

Used with permission from Lymphnotes.com
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• The lymph system carries the lymphocytes
  throughout the body to respond to antigens and
  communicate responses to other parts of the body.
• Lacovara Yoder, 2006

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• Lymph then travels through multiple lymphatic
  channels and nodes before returning to the venous
  system by the thoracic duct.
• Golshan and Smith, 2006

Used with permission by med-ars.it
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• Under normal conditions, the entry of fluid and
  other materials into the interstitial space is
  balanced by outflow of the lymphatic fluid from
  the limb, which maintains standard volume.
• Golshan and Smith, 2006

Used with permission from www.med-ars.it
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• 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
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• 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

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

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Identify Major Lymph NodesClick on the body
Cervical Nodes
Spleen
Axillary Nodes
Inguinal Nodes
Used with permission from cancerbackup.org
18
Review of the FlowClick 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
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
Mader, 1994
The fluid is then enters the subclavian veins
and is returned to the circulatory system.
www.lymphacare.com
19
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 bodys defense
  against disease.
• C. It circulates blood throughout the body

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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

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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.

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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

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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

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• The sentinel lymph node is the first lymph node
  draining from this tumor bed.
• Dow, 2002

Sentinel Node
Tumor
Used with permission from www.med-ars.it
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• 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

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• 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
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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

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Other Possible Risks

• Other causes that may lead to lymphedema include
• Scarring from a vesicant extravasation
• Local burns
• Lymph node metastasis
• Itano Taoka, 2005

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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
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• Correct! Malignant Melanoma can lead to
  lymphedema. Heres 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! Heres 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.
• Heres 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! Heres 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! Lets 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

• Yes! Sarcoma can lead to
• lymphedema. Heres 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

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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

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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 www.med-ars.it
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Stages of LymphedemaStage 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 gt 3 cm difference between extremities
• Itano Taoka, 2005

Used with permission from lymphacare.com
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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
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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 gt 5 cm difference between extremities.
• Itano Taoka, 2005

Photo Courtesy of Lymph Notes (www.lymphnotes.com)
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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!

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• 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

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

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

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

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• 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

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• Air travel gt 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

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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 www.lymphnotes.com
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
Used with permission by www.bellisse.com

• Manual Lymph Drainage (MLD)
• Performed by specially trained therapist
• Massaging connective tissue rather that deep
  muscles
• Stimulates the weakened lymphatic system and
  decongests the affected area to encourage
  formation of new pathways to unimpaired lymph
  nodes to reduce swelling.
• May also be taught to patient to perform on self.
• Thiadens, 2005 Dell Doll, 2006

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

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

Used with permission By knueppels.com
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• There are no medications available at this time
  to treat lymphedema.
• Diuretics should not be used to help lymphedema
  because they draw off excess water in the
  interstitial spaces, not the excess protein.
  Once the diuretic is out of the system, it pulls
  more water into the affected area.
• Holcomb, 2006

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Nursing Diagnosis

• Impaired physical mobility
• Disturbed body image
• Risk for infection
• Risk for impaired skin integrity
• Itano Taoka, 2005

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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.

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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.

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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!

• 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. 10 - 15
• D. 30 - 60
• Golshan Smith, 2006

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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.

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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
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. 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!

• MLD Manual lymph drainage is a gentle massage
  performed in the affected area to help move the
  lymph fluid back in the appropriate direction.
• It should be performed at least once a day for
  about 10-15 minutes.
• Academy of Lymphatic Studies, 2006

Used with permission by www.bellisse.com
Click HERE to return to question
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?(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
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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 www.med-ars.it
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

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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.
  1398-1405.
• Cole, T. (2006). Risks and benefits of needle use
  in patients after axillary node surgery.
  British Journal of Nursing 15(18) pp. 969-979.
• Dell, D.D. (2005). Spread the word about breast
  cancer. Nursing2005 35(10). pp56-63
• Dell, D.D., Doll, C. (2006). Caring for a patient
  with lymphedema. Nursing2006. 36(6). pp. 49-51.
• Dow, K.H. (2002). Pocket guide to breast cancer
  (2nd ed). Sudbury, MA Jones and Bartlett
  Publishers.
• Golshan, M., Smith, B. (2006). Prevention and
  management of arm lymphedema in the patient with
  breast cancer. Supportive Oncology 4(8). pp.
  381-386

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87

• Holcomb, S.S. (2006). Putting the squeeze on
  lymphedema. Nursing Made Incredibly Easy! 4(2).
  Pp26-34.
• Itano, J.K., Taoka, K.N. (2005). Core curriculum
  for oncology nursing (4th ed) Philadelphia, PA
  Elsevier Saunders.
• Lacovara, J.E., Yoder, L.H. (2006). Secondary
  lymphedema in the cancer patient. MEDSURG
  Nursing. 15(5). pp. 302-306.
• Lewis, M.S., Heitkemper, M.M., Dirsken, S.R.
  (2000). Medical-surgical nursing
• assessment and management of clinical problems.
  St. Louis, MO Mosby.
• Mader, S. (1994). Understanding human anatomy and
  physiology (2nd ed). Dubuque, IA Wm. C. Brown
  Publishers.
• Marrs, J. (2007). Lymphedema and implications for
  oncology nursing practice. Clinical Journal of
  Oncology Nursing. 11(1). pp. 19-21.
• National Cancer Institute (2006). www.cancer.gov.
  retrieved 4/5/07
• Nazarko, L. (2006). Understanding lymphedema in
  older people. Nursing Residential Care. 8 (6).
  Pp.254-258.

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

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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.

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