Integumentary Flashcards
What is the lymphatic system?
–One-way system designed to
transport lymph fluid through
specific deep and superficial vessels
called lymph vessels & nodes
–Lymph fluid contains water, fatty
acids, proteins, WBC’s, bacteria and
other cellular debris. 15%
Interperet Normal vs Abnormal Lymph Nodes…
Normal Lymph Nodes
- Supple
- Non-tender
- Mobile
Infected or Inflamed Lymph Nodes
- Firm and Enlarged
- Tender
- Warm
- Mobile
Malignant Lymph Nodes
- Firm and gradually growing in size
- Non-tender but also can be tender
- Matted or immobile
*When asked about BEST course of action, decrease exercise intensity and monitor vitals first.
How to measure a limb…
• Water Plethysmography (Water Displacement
Method)
• Gold standard for measuring limb volume for the
hands and feet
• Based on principle that an object displaces its
own volume of water
Circumferential Measurement (Tape Measure
method)
• Standard and most common means of measuring
limb volume
What are the stages of Lymphedema?
- There are 4 stages in total (0-3)
- Stage 0
–No visible changes
•Stage 1 (Mild)
–Slight reversible swelling
–Pitting edema occurs
–Stage 2 (Moderate)
- Moderate irreversible swelling
- Pitting edema (early stage 2)
- Non-pitting edema (late stage 2)
- Stemmer’s Sign
–Stage 3 (Severe)
- Severe swelling
- Skin is permanently damaged/deformed
- Large skin folds
A patient with stage 2 lymphedema presents with an
unexpected increase in right lower extremity edema. The patient
has itching and burning over the anterior right shin with
symptoms of excessive sweating, low grade fever, and dizziness.
Which of the following is the MOST likely present?
A. Dermatitis
B. Pulmonary embolism
C. Right sided CHF
D. Cellulitis
A. NO because limb swelling is not as common
B. NO because it would be more posterior
C. NO because this is bilateral
D. Final Answer!
Differential Dx of Lymphedema
–Unilateral Conditions
- DVT
- Post-thrombolytic syndrome
- Baker’s Cyst
- Arthritis
–Bilateral Conditions
- CHF
- CVI
- Dependent edema
- Kidney disease
- Liver disease
- Lipedema
Lipedema
• Excessive accumulation of fatty
deposits
– Found in upper & lower extremities
bilaterally and symmetrical
•Thighs, hips, buttocks, posterior arms
– There is normal functioning lymphatic
system however signs resemble
lymphedema
Telling the difference…
• Lipedema
–Female dominant
–Typically due to hormonal
imbalance (pregnancy,
puberty)
–Bilateral & Symmetrical
–Negative Stemmer’s sign
–Swelling stops at ankles/wrist
A patient presents with significant swelling in both lower extremities
extending to the ankles. The therapist would like to confirm the presence of lipedema while ruling out lymphedema. Which of the following tests would provide the MOST conclusive data
A. Ankle brachial index (ABI)
B. Blood pressure
C. Bioimpedance analysis
D. Girth measurement around large joints
C. Bioimpedance because fat slows down the signal. It can confirm the presence of fat.
Decongestive Therapy
• Comprehensive lymphedema treatment
composed of two phases
• Phase I – Treatment Phase
–Manual Lymph Drainage
–Compression bandages
–Exercise
–Meticulous Skin Care
• Phase II – Self-Management Phase
–Continuous bandaging or compression (garment during
the day/bandages at night)
–Exercise
–Skin Care
–MLD as needed
What is Manual Lymph Drainage?
• Theory
–Improving lymphatic flow by guiding the fluid
gently around blockages and into proximal ducts
for removal.
• Procedure
–Patient should be lying supine with affected
extremity elevated
–Central areas and uninvolved proximal nodes are
cleared first
–Light and gentle strokes distal to proximal starting
at the most proximal aspect of the extremity first.
Why is compression important?
–50% of edema reduction is equated to
proper compression post MLD. (save your work)
–Bandages are primarily used in CDT phase
I but will be mostly used only at night in
phase II
–Graded compression (distal > proximal)
Types of Compression-Short Stretch
• Short Stretch Bandages (Comprilan)
–Latex-free elastic bandage
–Stretches to 60% of resting length
–High Working Pressure
•temporary resistance to the muscle
produced as the muscle contracts
–Low Resting Pressure
•Constant pressure of the bandage in the
absence of muscle contraction
Types of Compression- Long Stretch Bandage
• Long Stretch Bandages (Ace Bandage)
–Low Working Pressure
• temporary resistance to the muscle produced
as the muscle contracts
–High Resting Pressure
• Constant pressure of the bandage in the
absence of muscle contraction
–Often times cuts off the lymphatic flow in
superficial lymphatic vessels exacerbating
the lymphedema
Phase 2 CDT…
7
TYPES OF COMPRESSION
• Long Stretch Bandages (Ace Bandage)
–Low Working Pressure
• temporary resistance to the muscle produced
as the muscle contracts
–High Resting Pressure
• Constant pressure of the bandage in the
absence of muscle contraction
–Often times cuts off the lymphatic flow in
superficial lymphatic vessels exacerbating
the lymphedema
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PHASE II CDT
Use of compression garments and
short-stretch bandages are critical to
success.
- Custom vs. pre-fabricated garments
- Turnover rate
- Number of garments needed
- Changes in limb size
Rules of Pneumatic Compression…
• High pressures in the 70 to 100 mm Hg
range can damage lymphatic vessels in as
few as 3 to 5 minutes.
• Therefore it is very likely that high pump
pressures could damage lymphatic
vessels.
• 20 to 60 Normal PSI range
–40 – 50 mmHg with lower extremities
–30 – 40 mmHg with upper extremities
