NPTE Final Frontier > Lymphatics > Flashcards

Lymphatics Flashcards

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1
Q

Lymphatic system:
What is Lymph?

A
  • Portion of interstitial fluid entering the lymphatic system
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2
Q

Lymphatic organs

A

Nodes, tonsils, thymus, thoracic duct, bone marrow

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3
Q

MAJOR lymph nodes

A
  • submax, iliac, mesenteric, inguinal, popliteal, supraclavicular, parasternal
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4
Q

Lymphatic system we think of what?

A

Immune system
Infx’s fighter

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5
Q

Flow of Lymph:

Think SMALL to BIG (all ends up in Subclavian veins)

A
  1. FROM lymphatic capillaries
  2. Lymphatic collecting vessels
  3. Lymph nodes (filter lymph)
  4. Lymphatic trunks
  5. Lymphatic ducts
  6. Subclavian veins INTO bloodstream
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6
Q

So you know the flow of Lymph. Now where does it get drained? MAJORITY vs RUE/Face?

A
  • ENTIRE L. SIDE and B/L LE’s drained by Thoracic duct
  • RUE/Face (ONLY HERE) drained by Lymphatic duct
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7
Q

Lymphatic Load:
aka how much present

A

AMT of lymph fluid transported

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8
Q

Transport capacity–>
aka HOW MUCH can be transported

A

MAX amt of fluid that lymphatic system CAN TRANSPORT

Bw the two (Load vs Capacity): INC load + DEC capacity==> Lymphedema

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9
Q

INC lymphatic load + DEC transport cap== Lymphedema

Give some ex’s

A
  1. Venous insuff. + blood pooling==> INC lymphatic LOAD (no pump blood, accumulation)
  2. Lymph node removal==> DEC transport capacity
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10
Q

What is Lymphedema?

A
  • CHRONIC disorder, abnormal accumumulation of lymph in the tissues of one or more body regions
  • NOTE: 2 types (Primary vs 2*)
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11
Q

Primary Lymphedema==>

A

ALWAYS been there
Congenital or hereditary

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12
Q

Secondary Lymphedema ==>

A

Injury to one or more components of lymph system
EX. lymph node removal

caps-vessels-nodes-trunks-ducts-SubC veins

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13
Q

Practice!!
76yo female w/ dx of SECONDARY lymph. Pt states she had breast cx last year w/ sx to remove cx. All of these COULD be causes of secondary lymph.

A
  • infx
  • fibrosis
  • Chronic venous insuff.

NOTE: If you see Milroys– this is primary/congenital cause= Primary

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14
Q

Severity of Lymphedema
How is Severity described?

A

Severity of changes that occur in the skin, and subQ tissues

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15
Q

Severity of Lymphedema
Looking @ Edema (severity lvls)
Summarize each

Severity inc’ing from Pitting–> Weeping

A
  • Pitting-“makes a pit”–short duration edema w/ little or NO fibrotic changes in skin or SubQ
  • Brawny (strong guy, feels hard)– NO PIT. More severe form of swelling w/ progressive, fibrotic changes in SubQ
  • Weeping (crying, leaking)– MOST severe, LONG duration. Fluid leaks cuts/sores–sig impaired wound healing–> EXCLUSIVELY in LEs
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16
Q

(+) Stemmer Sign in a nutshell…

A

CANNOT PINCH THE SKIN

==> WORSENING OF CONDITION

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17
Q

Stemmer Sign KNOW IT!

A

(+) = Stage II or III Lymph.
(+)= dorsal surf. of skin cannot be pinched (lifted) vs uninvolved
==> Worsening

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18
Q

Stages of Lymphedema

Lymph03dema

A

4 Stages total:
**Staged 0-3 **

Lymph03dema

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19
Q

Stages of Lymph03dema

0(best)-3(worst)

A

ALL HERE

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20
Q

Lymph03dema Stages:

Stage 0 (Latency)

A

Latency
- NO clinical edema–> report heaviness
- (-)Stemmer–bc NO edema!
- Tissue/skin appear NORMAL

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21
Q

Lymph03dema Stages:

Stage 1: **Reversible **

Think “Pitting”
SEE REVERSIBLE—-W/ ELEVATION!! BC GRAVITY!!!

A

Reversible
- Edema present (soft/pitting)
- Edema–> INCs w/ stand/activity BUT reduces w/ elevation (gravity assists)
- (-)Stemmer–bc reversible!

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22
Q

Lymph03dema Stages:

Stage 2: Spontaneously IRreversible

NO longer pitting–> progresses to Brawny (strong guy, hard)

Key words: Hard, Fibrosclerotic, proliferation adipose

A

Spontaneously Irreversible
- Hard swelling; progresses to NONpit BRAWNY edema
- (+)Stemmer, (still neg. in early stage II)
- Tissue appears fibrosclerotic (hard); prolif of adipose

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23
Q

Lymph03dema Stages:

Stage 3: Lymphostatic Elephantiasis

Elephant one

A

Lymphostatic Elephantiasis
- Edema!–SEVERE, Brawny, NONpit
- (+)Stemmer…obvi.
- Skin Changes!–papillomas, deep skinfolds, warty protrusions, hypERkeratosis, mycotic infxs—SEE THESE WORDS==STAGE 3!!!!
- Bacterial/viral infxs common

SKIN CHANGES==STAGE 3!!!

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24
Q

PRACTICE!
Female referred w/ lymphedema. NOTABLE swelling HARD and fibrotic, (+) stemmer, hypERkeratosis (skin changes!!!). Which stage?

A

Stage 3
SKIN CHANGES!!!

0= latency, 1= reversible, 2= spont. irreversible, 3=elephantiasis

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25
How do you remember the **Grading scale of edema and Pitting??** | Pitting is ONLY Stage 1 and EARLY Stage 2
$1= 4 quarters
26
# Grading Scale of Edema --$1=4 quarters 1+
Mild, barely perceptible (no secs) indent **<.25in pitting** | 4 quarters!
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# Grading Scale of Edema --$1=4 quarters 2+
Moderate, easily ID'd depression; **return to norm w/in 15s** **.25-.5in** | 4 quarters!!
28
# Grading Scale of Edema --$1=4 quarters 3+
Severe, depression takes **15-30s rebound** **.5-1in** | 4 quarters!
29
# Grading Scale of Edema --$1=4 quarters 4+
VERY severe, depression **lasts >30s+** **>1in**
30
# Grading Scale of Edema --$1=4 quarters 4+
VERY severe, depression **lasts >30s+** **>1in**
31
Practice! 45yo lymph. L. leg. **Early** stage II (will see pitting). Pitting scale 3+ (.5-1), 15-30s
Severe, 15-30s rebound, .5-1in pitting Fibrosclerotic tissue
32
Practice! PT exams 46yo w/ radical mastectomy w/ node removal. INITIAL dev. of lymphedema?
Decd flex. of fingers **bc DISTAL extremities swell FIRST!**
33
**LIP**edema **How can you remember this?**
We have **2 Lips! Upper lip; Lower lip** **Lip**edema is ALWAYS **B/L** 2 lips, so 2 limbs! B/L!!! **ALSO** - LI**P**--> **P**roximal areas (Butt/Thighs)--> **UEs NOT affected**
34
**LiP**edema facts
- B/L, only LEs!! - PROXIMAL areas--> butt/thighs, NOT DISTAL, NOT UEs - Affects skin elasticity, skin sensitive to pressure/touch---bruise/painful
35
Practice! 49yo pt w/ swollen leg. PT suspects LIPedema. What will NOT be seen?
High likelihood of dev. cellulitis (bc cellulitis seen in **stage 3 lymph.** | NO CELLULITIS IN LIPEDEMA NO STEMMER SIGN IN LIPEDEMA BC DISTAL not aff.
36
Lymphedema vs LIPedema
NOTE - Distribution- Lymp Uni or Bilat; Lip is B/L - Cellulitis common in lymph. - Stemmer sign- +lymph; -Lip
37
Diff Dx based on picture
A: Lymphedema NOT: - HF--> will see B/L pitting edema - LIPedema--> B/L and NEVER distal - Chronic venous insuff--> will see hemosiderin stain, dark pigmentation
38
Measurements for Edema **3 and WHEN to use/keywords to know**
1. **Girth** measure--> for PROX. EDEMA--use **10cm intervals from landmark** 2. **Volumetric**--> for DISTAL EDEMA-- tank of water 3. **Bioimpedance**--> KEY WORD: **used for pre/post-SURGERY**
39
Dx of Lymph03dema **ONLY ONE TO KNOW!**
Lymphoscintigraphy: **measured during REST and EXERCISE** - ID's **Lymphatic INSUFF**
40
Lymph**angITIS==**
Inflammation of lymph VESSELS think "angio" is vessels
41
Lymph**adenITIS**
Inflamm of lymph NODES
42
Lymphadeno**PATHY**
**Enlargement** of lymph **nodes**
43
For NPTE: If stem asks **PROXIMAL edema measure==**
GIRTH measure
44
For NPTE If stem asks **Distal (UE/LE) edema measure**
Volumetric
45
For NPTE If stem asks **Pre/Post SURGERY edema measure==**
BioImpedance
46
For NPTE IF stem asks **Lymphatic INSUFF==**
Lymphoscintigraphy
47
Practice! PT assessing **lymph nodes** 6mos post-op chemo. When assessing lymph nodes, which presentation LEAST likely req's referral? Aka **what SHOULD lymph nodes feel like?**
SHOULD BE: - soft - free moving - NON-tender - NOT easily palpated - UP to 1cm diameter
48
Palpation of lymph nodes
SHOULD BE: - soft, non-tender, non palpable, up to 1cm Abnormal: **report to physician if abnorm** - tender, hard, immobile - Metastatic tumor
49
Mgmt of Lymphedema **Main ideas/interventions**
**MAIN goal==** MIN. lymphedema OR return to **latency stage (stage 0)** - Interstitial press. INCd by EXT forces-- **MLD or Compression**--pushes fluid into bloodstream - Dynamic press. changes w/in body-- **Diaphragmatic breathing or mm contracts (pump)** - **MM contracts COMBO'd w/ EXT forces (see above) from bandage or compression EVEN MORE EFFECTIVE in mvmt of fluid
50
Manual Lymphatic Drainage: **MLD** | KEY THINGS TO REMEMBER!
- ALWAYS **LOW stretch (SHORT-stretch)** - Clear fluid PROX to DIST - Direction of massage--> Dist to Prox
51
MLD: **Guidelines**
- **Proximal congestion** in trunk, groin, butt, axilla cleared FIRST **to make room for fluid from DIST areas (think traffic jam)** - The **direction of massage** is twrds specific lymph nodes--usually involves **DIST-> PROX stroking** (effleurage) - Fluid in **involved extremity cleared**-- FIRST **proximal portion** THEN **distal portion**
52
CDT aka Complete Decongestive Tx **Phase I** | Phase II in pics
- MLD (Decongest): Prox to Dist areas (the DIRECTION of stroking is DIST-> PROX (bc want to move fluid back proximal, but start in PROX areas to clear traffic) - Exercises--mm pump--Prox--> Distal mm's - Garments-- SHORT (LOW) stretch, pressure more distal
53
Compression Therapy Type of compression depends on....
Phase!
54
Compression therapy: **Phase 1** | what do you HAVE TO REMEMBER?
LOW (SHORT) STRETCH BANDAGE!!! ==HIGH WORKING PRESSURE, LOW resting pressure *short stretch meaning it doesnt like to stretch so when you do stretch it the tension is HIGH and will be working HARD (High) when stretched*
55
Compression Tx: **Phase 1:**
- ONLY LOW (SHORT) stretch== LOW resting pressure (limb @ rest) but HIGH working pressure - Day/Night - **Active reduction phase--> LOW stretch** High (long) stretch-- ACE; NOT RECOMMENDED--> mostly sports inj's
56
Compression Tx for Lymphadema More on this
We want LOW (SHORT) stretch--> doesnt actually stretch much means HIGH working pressure bc you FORCE stretch
57
Practice! PT examining 46yo pt w/ radical mastectomy (UE). INtervention?
Trunk and Axilla (proximal) **decongested FIRST** f/b arm/ hand | Remember Traffic Jam!!! Clear proximal first (masage dir. opp)
58
MM ex's for UE lymphedema
Remembe Proximal ex's first!!!
59
Practice! PT dev. ex program for pt w/ UE Lymph. Which ex do first?
CERVICAL rotation! NOTES: **- Trunk/Spine always FIRST** (PROXIMAL!) - **DEEP breathing always always always FIRST BEFORE ANYTHING!!!**
60
Last things to rememer
NO BP on lymphadema limb *Even if B/L-- Usually Asymmetrical (one more swollen vs other)*
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