lymphedema Flashcards
(52 cards)
1
Q
lymphatic system (6)
and function
A
- tonsils - spleen - thymus gland - lymph nodes - lymphatic vessels - peyer’s patches (intestines)
- prevents interstitial edema - assists in the digestion of fats - immunological functions - one way system
2
Q
lymph nodes
A
- 600-900
- drain regions
- make WBC
- filter and concentrate fluid
- drain all tissues except for CNS
3
Q
superficial lymphatic system
A
- like the roots of a plant
- from the most distant parts of the body to the venous angles
- anatomical variation is common
4
Q
deep lymphatic system
A
- thoracic duct drains approx 3/4 of the body
- right lymphatic duct drains approx 1/4 of the body
5
Q
lymphatic system carrying
and what happens to it?
A
proteins - cells - water - fats
- eventually lymph fluid returns to the venous system and becomes part of the plasma
- must have healthy heart, lungs, and kidneys to process that fluid!
6
Q
lymph capillaries
A
- single cell layer
- no basement membrane
- anchoring filaments
- swinging flaps to prevent backflow
7
Q
lymphatic transporting vessels
A
- collectors: basement membranes - muscular walls - valves
2. trunks/ducts: largest vessels - thoracic duct - right lymphatic duct
8
Q
lymphedema
A
abnormal accumulation of protein rich fluid in the interstitial spaces
- results in chronic inflammation and reactive fibrosis of the tissues
- progressive
9
Q
lymphedema: clinical sign
A
pitting edema
- feels warm and soft - then soft playdough - the silly putty
10
Q
lymphedema: typical locations
A
- extremities (uni or bilateral)
- trunk and breasts
- genitals
- intestinal
- head and neck
11
Q
primary lymphedema
A
- lymphatic dysplasia
- can be hereditary
- often onset is at menstruation or pregnancy
12
Q
secondary lymphedema
A
- lymph node surgery
- radiation therapy
- traumatic injury to vessels or nodes
- surgical scarring
- malignant lymphedemas
13
Q
stage 0
A
- latency
- patient is at risk for lymphedema, no visible and/or palpable swelling
- check for subjective complaints
- may use bioelectrical impedance analysis (BIA) to detect changes on affected side
- treatment?
14
Q
stage 1
A
- reversible
- visible swelling (may be fluctuating)
- check for subjective complaints
- mainly protein-rich fluid which responds to elevation
- treatment?
15
Q
stage 2
A
- spontaneously irreversible
- visible, chronic swelling
- protein-rich fluid and fibrosis
- elevation may provide some relief but will not be very effective
- treatment?
16
Q
stage 3
A
- lymphostatic elephantiasis
- visible, chronic swelling
- protein-rich fluid, fibrosis, skin changes and cellulitis
- infections common
- treatment?
17
Q
usual S&S lymphedema
A
- onset may be slow or rapid
- progressive
- pitting
- often starts distally (squaring of toes, stemmer’s sign positive, loss of anatomical, asymmetric if bilateral)
- cellulitis is common
- discomfort is common (heaviness, achiness, etc)
- skin changes (later stages: hyperkeratosis, papillomas)
- ulcerations are unusual
- in contrast with venous disease the skin maintains hydration and elasticity for longer in the disease process
18
Q
hyperkeratosis
A
over abundance of epidermal thickening with lymphedema
- changes start distally on the limb: hardened tissue, can be moss like, abrasive in advanced presentation
19
Q
differential dx (9)
A
- venous insufficiency/obstruction
- congestive heart failure
- hepatic/renal disorders (biliary)
- nutritional disorders
- lipedema
- myxedema (thyroid disease)
- CRPS
- fluid retention symptoms
- immobility/dependency
20
Q
CHF/cardiac edema
A
- bilaterally symmetric LE edema
- lacks skin coloring changes compared to CVI
- soft pitting
- reduces with elevation
- shiny skin due to fluctuations in dependent edema
- lower leg or entire leg
- toes usually uninvolved
- dyspnea
- orthopnea
- diuretics helpful
21
Q
decompensated CHF
A
- edema treatment is contraindicated!
- orthopnea
- wet cough
- pleural effusion
- dyspnea on exertion
- swelling is moving into other areas of the body, not just the lungs
22
Q
kidney disease
A
- initially soft edema similar to cardiac edema
- becomes woody or indurated as kidneys fail
- bilaterally symmetric
- no breathing changes associated
- typically lower legs only unless severe failure then progresses to thighs and trunk
23
Q
acute renal failure
A
sudden loss of kidney function caused by an illness, an injury, or a toxin that stresses the kidneys (may recover)
- edema treatment is contraindicated!
- tx mobilizes fluid back to systemic circulation
- kidneys must filter after traveling to the heart and lungs
- may be treated if on dialysis, but carefully
24
Q
chronic kidney disease
A
a long and usually slow process where the kidneys lose their ability to function
25
end-stage renal disease
when the kidneys have completely and permanently shut down
26
liver disease
- bilateral and symmetric
- commonly starts in lower legs, progresses rapidly into the thighs and the trunk
- usually soft and pitting
- reduces with elevation initially
- may be associated with jaundice and right abdominal pain
27
liver disease etiology
- hepatitis
- metastases to liver
- malnourishment (hypoproteinemia)
- severe alcoholism
28
acute DVT
* treatment is contraindicated!
- check with MD regarding ambulation and exercise prescription
- blood thinners must be in therapeutic range
- no MLD over the DVT site until cleared by MD
29
tests for DVT and risk factors (8)
1. doppler ultrasound
2. d-dimer test: helps determine if further testing is needed to diagnose diseases and conditions causing hypercoagulability
3. wells prediction rule!
* risk factors: cancer - recent surgery - immobility - trauma - meds (birth control, hormone therapy, antihormone therapy) - obesity - smoking - sitting
30
indications for compression
- persistent lymphedema
- open wounds
- venous insufficiency
31
contraindications for compression
- acute DVT
- acute renal failure
- arterial disease
- CHF (decompensated)
- relative contra: allergy to dressings
32
late stage chronic venous insufficiency
- upside down champagne bottle appearance
- becomes less fluid
- less fluctuation throughout the day
- hemosiderin staining (brownish discoloration)
33
cellulitis
* treatment is contraindicated!
- localized patchy redness
- painful
- warm
- swollen
- distal > proximal
- fever
- chills
34
combined insufficiency and treatment
- excessive fluid from non-healing humeral fracture
- history of axillary node removal
- like the bath and shower are running at the same time in a tub with a clog in the drain. water keeps on coming with no where to go
- treatment: still has non healed fracture, most of excessive proteins have been removed-reducing the load on the lymphatic system, tissue is much softer
35
5 components of complete decongestive therapy (CDT)
1. manual lymph drainage
2. compression bandaging
3. exercise
4. skin and nail care
5. instruction in self-care
36
compression in lymphedema
- bandaging during CDT and night time
- comp garments for daytime use
- bandaging alternatives (short stretch bandages - long stretch bandages sports - unna boot - profore - coban2)
37
short stretch bandage
- main component of lymphedema bandage
- comprilan and rosidal
- all cotton! no rubber or latex
- used as multi-layer bandage
- therapist/patient controls amount of pressure/tension
- suitable as long term application (hours/day)
- washable and reusable
*resting pressure and working pressure (resistance against mm and joint movement). Provide low resting pressure and high working pressure (long stretch vice versa) to decrease lymphedema
38
law of laplace
pressure = tension / radius
39
principles of lymphedema bandaging
- overlap bandages 50%
- manage the tension while applying the bandage (pre-stretch bandage by about 50%)
- maintain functional mobility to enhance the muscle/joint pump
- prevents re-accumulation of fluid
- breaks up lymphostatic fibrosis
40
indications for lymphedema bandaging
- lymphedema
- chronic venous insufficiency (CVI)
- combo venous and lymphatic edema
- lipedema
- post traumatic edema
- post surgical edema
41
contraindications for lymphedema bandaging (6)
- acute infections (MD needs to clear pt)
- arterial wounds
- arterial disease (ABI 0.8 or below)
- acute DVT
- cardiac edema (untreated CHF)
- acute trauma without diagnosis
42
relative contraindications for lymphedema bandaging
- sensory deficits
- malignancy
- diabetes (small vessel arteriole and sensory deficits, toe bandaging my be contra)
- paralysis
- poor cognition or altered mental status
- sensitivity to the products used for bandaging
43
manual lymph drainage (MLD)
- increases lymph flow
- increases reabsorption of protein-rich fluid
- promotes relaxation
- analgesic effect
44
contraindications MLD (5)
- acute DVT
- acute infection
- decompensated CHF
- pleural effusion
- untreated kidney failure
45
relative contraindications MLD (5)
- active cancer
- malignant lymphedema
- subacute DVT
- dialysis
- treatment in active radiation field
46
foeldi
for optimal venous and lymphatic flow
- full joint ROM
- deep breathing
47
exercise + bandaging
- bandages counterbalance elastic insufficiency and increase tissue pressure as well
- it has been shown that there is a positive correlation between tissue pressure and lymph flow (working pressure)
- bandaging, in combo with movement, softens fibrosis and pitting edema
- muscle contraction and elongation, and arterial pulsation, increase lymphangiomotoricity
48
exercise
while compressed
- increases muscle and joint pump
- softens fibrosis
- facilitates lymphatic drainage
49
ideal exercise for active phase
- includes active movements with bandages on
- exercise not only the muscles of the edematous region, but also the neck and trunk to facilitate lymph flow centrally
- uses gravity or light resistance throughout the range of motion to both shorten and elongate tissues
- includes deep breathing
- increases the heart rate
50
aquatic exercise benefits
- buoyancy
- promotes relaxation
- isokinetic exercise reduces inflammatory response
- gradient compression with hydrostatic pressure of 22.4mmHg for every 12in of immersion
51
aquatic exercise beware
- too much too soon
- risk of hypotension when exiting the water
- erythema and increased lymph load
- muscle soreness with floatation-type resistance and eccentric contractions
52
self care
- self compression
- garments
- self MLD
- exercise
- skin care
