Lymphedema

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

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

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

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

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

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

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

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

9. Lymph vessels usually do not have a large basement membrane, which allows large molecules to enter that cannot be reabsorbed readily by the venous system. • Golshan and Smith, 2006 Used with permission by www.med-ars.it Table of Contents

10. Once this interstitial fluid is absorbed, it moves through the lymphatic vessels, and is considered lymph fluid. • As lymph fluid moves through the lymphatic system, it passes through lymph nodes. Lymph nodes filter harmful substances and contain lymphocytes that activate the immune system. • National Cancer Institute, 2006 Used with permission from Lymphnotes.com Table of Contents

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

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

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

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

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

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

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

18. Review of the “Flow”Click on the screen Interstitial fluid has diffused from blood capillaries The lymph capillaries absorb this interstitial fluid The capillaries join to form vessels that carry the lymph fluid back to the heart. Thoracic Duct The lymph fluid then enters either the thoracic duct or right lymphatic duct On the trip back, the lymph fluid passes through lymph nodes, where it is cleaned and filtered Mader, 1994 www.lymphacare.com The fluid is then enters the subclavian veins and is returned to the circulatory system.

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 body’s defense against disease. • C. It circulates blood throughout the body Table of Contents

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

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

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

23. Risk Factor: Surgery • Any surgery that dissects or removes lymph nodes increases the risk of lymphedema by impairing the lymph flow. • Marrs, 2007; Lacovara & Yoder, 2006 • Common cancers that may require surgical alterations of the lymph nodes include breast cancer, melanoma, gynecological cancers, head and neck, prostate, testicular, bladder, or colon cancer. • Thiadens, 2005 Table of Contents

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

25. Risk Factor: Radiation • Radiation therapy to the axillary or groin region around the lymph node can cause fibrosis and scarring of the tissue and therefore cause lymphedema to occur. • Golshan & Smith, 2006 Table of Contents

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

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

28. A technique called Sentinel Node Biopsy can be performed, which the surgeon finds and removes this first node and sends it for a pathologic examination. • Dell, 2005 • If the sentinel node is benign, no further lymph node removal is needed. • Thaidens, 2005 Table of Contents

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

30. Other Risks: Infection and Injury • Things such as infections, bug bites, and bee stings may lead to lymphedema in a high-risk patient. • Trauma to the extremity at risk may also cause lymphedema. • The rationale is lymphatic flow increases to the affected site, however there is an obstruction or defect in the lymphatic system, causing lymph fluid to leak. • Dell & Doll, 2006 Table of Contents

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

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

33. Correct! Malignant Melanoma can lead to lymphedema. Here’s how: • Malignant melanoma can metastasize to regional lymph nodes. Treatment for malignant melanoma may involve surgical resection; depending on location and extent of disease, the lymph nodes may need to be removed. • Itano & Taoka, 2005 Click here to return to question Possible risk areas: www. cancebackup. org AxillaryNodes Inguinal Nodes

34. Right! Here’s how: • When you think of gynecologic cancers (ovarian, uterine, cervical), think location. Surgical removal of the inguinal lymph nodes puts the patient at risk for lower extremity lymphedema. Click HERE to return to question www. cancebackup. org Inguinal Nodes

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

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

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

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

39. Diagnosing Lymphedema • Painless swelling of the arms or legs, which may get worse during the day and better at night. • Warmth or achiness in the extremity. • A feeling of tightness, heaviness, tingling, numbness, or weakness in the affected extremity. • Redness of the affected extremity. • Bracelets, rings, or shoes may become tight. • Lacovara & Yoder, 2006 Table of Contents

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

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

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

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

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

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

46. Correct! Stage II lymphedema is not reversible. With treatment, lymphedema may be minimized, but it is never truly “cured”. • Continue on with the tutorial to learn about treatment options! Table of Contents

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

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

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

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