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Arm and Leg Swelling After Cancer With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen. Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs. This swelling occurs because of one of several factors. First, the swelling begins after lymph nodes have been removed for cancer biopsies. Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system. Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling begins. This swelling is called lymphedema and it can effect either your leg or your arm. The swelling that occurs is permanent, and while it is not curable it is treatable. Hopefully, in the future with radiological scans becoming more sensitive and with increased use of such techniques such as the small needle biopsy, we can put an end to this epidemic of secondary lymphedema from cancer biopsy. In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered There are several groups of people who experience leg or arm swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by. Group One This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema. Group Two Another extremely large group that experiences permanent leg or arm swelling arecancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid. In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries. This is also referred to as secondary lymphedema. Group Three Group three consists of people who have leg or arm swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time. The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later. This type of leg or arm swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system. This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics. Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system. A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema. If you are an at risk person for arm lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them. Unexplained aching, hurting or pain in the arm Experiencing “fleeting lymphedema.” This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown arm lymphedema. Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the hand, or between the elbow and hand. This is an indication of early lymphatic malfunction. Any arm inflammation, redness or infection. You may experience a feeling of tightness, heaviness or weakness of the arm. The symptoms for leg lymphedema are very similar to ones for the arm. The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MLD), there are variances, but most involve these two type of treatment. It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally. With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunocompromised. Draining wounds that leak lymphorrhea which is very caustic to surrounding skin tissue and acts as a port of entry for infections. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids. Loss of Function due to the swelling and limb changes. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections. Sepsis, Gangrene are possibilities as a result of the infections. Possible amputation of the limb. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections. Chronic localized inflammations. No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation. For extensive information on lymphedema, please visit our home page: Lymphedema People http://www.lymphedemapeople.com © Copyright 2005 by Pat O'Connor and Lymphedema People. Use of this information for educational purpose is encouraged and permitted. It must be available free and without charge and not used for financial renumeration or gain. Please include an acknowledgement to the author and a link to Lymphedema People. See also our copyright policy on the welcome page. This patient summary is adapted from the summary on lymphedema written by cancer experts for health professionals. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Lymphedema is a swelling of a part of the body, usually an arm or leg, that is caused by the buildup of lymph. Lymph is a nearly colorless fluid that travels throughout the lymphatic system and carries cells that help fight infection and disease. Lymphedema can be caused by cancer or the treatment of cancer. This brief summary describes lymphedema, its causes and treatment. Lymphedema is the buildup of lymph in the tissues, mainly in the fat just under the skin, and is caused by a problem in the lymphatic system. Lymphedema is an abnormal collection of too much tissue protein, fluid (edema), chronic inflammation, and thickening and scarring of connective tissue. The lymphatic system is made up of vessels that are similar to blood vessels, but it carries lymph instead of blood. Unlike the blood system, which circulates through every part of the body, the lymphatic system drains lymph away from each part of the body. The lymphatic system collects fluid and protein from body tissues and returns it to the blood stream. Proteins and substances too big to fit into veins are moved through the lymphatic system. Edema may occur when these substances are in excess and the lymphatic system becomes overwhelmed or blocked. Lymphedema is categorized as either primary or secondary. Primary lymphedema is a rare inherited condition in which lymph nodes and lymph vessels are absent or abnormal. Secondary lymphedema is usually caused when the lymphatic system is blocked or cut and may be caused by infection, cancer, or scar tissue. The most frequently affected lymph nodes are in the pelvis and legs or under the arms. Acute versus chronic lymphedema There are several types of lymphedema. The first type is acute, temporary, and mild lymphedema that occurs within a few days after surgery that has involved the cutting of lymphatic vessels. It usually gets better within a week after keeping the affected arm or leg raised and by pumping the muscle that is associated with the affected limb (for example, making a fist and releasing it). The second type of lymphedema is acute and painful and occurs 4-6 weeks after surgery. This type of lymphedema is caused by swelling of the lymphatic vessels. It is treated by keeping the affected arm or leg raised and taking anti-inflammatory drugs. The third type of lymphedema is an acute form involving the skin, often occurring after an insect bite or minor injury or burn. It may occur on an arm or leg that is chronically swollen. This third form of edema is treated by keeping the arm or leg raised and by taking antibiotics. The fourth and most common form of lymphedema is slow and painless and usually occurs 18-24 months after surgery to remove a tumor or lymph nodes. If it develops later, it may mean that the tumor is coming back. Acute lymphedema is a temporary condition that lasts less than 6 months. The skin indents when touched and stays indented, but there is no hardening of the skin. A patient may be more likely to develop lymphedema if he or she has surgical drains that leak protein into the surgical site; inflammation; no movement of the arm or leg; or a temporary lack of lymphatic function in one area of the body. Chronic lymphedema is the hardest of all types of edema to treat. The damaged lymphatic system of the affected part of the body is not able to handle the increased fluid. This may happen when a tumor recurs or grows in an area of lymph nodes; when infection and/or injury of the lymphatic vessels occurs; when there is lack of movement of the arm or leg; after radiation therapy or surgery; with medical conditions such as diabetes, kidney problems, high blood pressure, congestive heart failure, or liver disease; or when preventive measures have not been taken after surgery. Lymphedema may also occur when cancer or cancer treatment causes loss of appetite, nausea, vomiting, depression, anxiety, or problems with metabolism. A patient who is developing lymphedema will have soft, pitting edema that is helped by raising the arm or leg and by wearing elastic support garments. Continued problems with the lymphatic system cause fluid to flow back into the tissues, and the condition may become worse. This causes pain, heat, redness, and swelling as the body tries to get rid of the extra fluid. The skin becomes hard, stiff, and non-pitting and is no longer helped by raising the arm or leg or using elastic support. Patients with lymphedema are more susceptible to infection. No effective treatment is yet available for patients with advanced chronic lymphedema. Edema may reoccur more easily in patients who have had lymphedema. Factors that can lead to the development of lymphedema include radiation therapy to the area where the lymph nodes were surgically removed, problems after surgery that cause inflammation of the arm or leg, being overweight, the number of lymph nodes removed in surgery, and being elderly. Patients who are at risk for lymphedema are those with: - Breast cancer if they have received radiation therapy or had lymph nodes removed. Radiation to the underarm area after the lymph nodes have been removed increases the occurrence of lymphedema. This also include men who have experienced male breast cancer. - Melanoma of the arms or legs if the patient has had lymph nodes removed from the underarm area and/or received radiation therapy. - Prostate cancer treated by radiation therapy to the whole pelvis or by surgery. - Cancer of the female reproductive tract that is advanced, treated with surgery to remove the lymph nodes, or treated with radiation therapy. - Cancer that has spread to the lower abdomen, such as metastatic ovarian, testicular, colorectal, pancreatic, or liver cancer. The pressure from the growing tumor can destroy the lymphatic vessels and block lymphatic drainage. Specific criteria for diagnosing lymphedema do not yet exist. About half of patients with mild edema describe their affected arm or leg as feeling heavier or fuller than usual. To evaluate a patient for lymphedema, a history and physical examination of the patient should be completed. The history should include any past surgeries, problems after surgery, and the time between surgery and the onset of symptoms of edema. Any changes in the edema should be determined as well as any history of injury or infection. Knowing the medications a patient is taking is also important for diagnosis. Prevention Patients at risk for lymphedema should be identified early, monitored, and taught self-care. A patient may be more likely to develop lymphedema if he or she eats an inadequate diet, is overweight, is inactive, or has other medical problems. To detect the condition early, the following should be examined: weight, measurements of the arms and legs; protein levels in the blood; ability to perform activities of daily living; history of edema, previous radiation therapy, or surgery; and other medical illnesses, such as diabetes, high blood pressure, kidney disease, heart disease, or phlebitis (inflammation of the veins). It is important that the patient know about his or her disease and the risk of developing lymphedema. Poor drainage of the lymphatic system due to surgery to remove the lymph nodes and/or radiation therapy may make the affected arm or leg more susceptible to serious infection. Even a small infection may lead to serious lymphedema. Patients should understand the dangers of developing lymphedema and should be taught about arm, leg, and skin care after surgery and/or radiation therapy (see Table I below). It is important that this care continues for life, since lymphedema can occur 15 or more years after surgery. Breast cancer patients who follow instructions about skin care and proper exercise after mastectomy are less likely to experience lymphedema. Lymphatic drainage is improved during exercise, therefore exercise is important in preventing lymphedema. Breast cancer patients should do hand and arm exercises after mastectomy. Patients who have surgery that affects pelvic lymph node drainage should do leg and foot exercises. The doctor determines how soon patients should start exercising after surgery. Physical therapists should develop an individual exercise program for the patient. Better recovery occurs when lymphedema is discovered early, so patients should be taught to recognize the early signs of edema and to tell the doctor about any of the following symptoms: feelings of tightness in the arm or leg; rings or shoes that don't fit; weakness; pain, aching, or heaviness; redness, swelling, or signs of infection. Use an electric razor for shaving -wear gardening and cooking gloves; use thimbles for sewing -take care of nails; do not cut cuticles Legs -keep the feet covered when going in the ocean -keep the feet clean and dry; wear cotton socks -cut toenails straight across; see a podiatrist Either arms or legs -suntan gradually; use sunscreen -clean cuts with soap and water, then use antibacterial ointment -use gauze wrapping instead of tape -talk to the doctor about any rashes -avoid needle sticks of any type in the affected arm or leg -avoid extreme hot or cold, such as, ice packs, heating pads -do not overwork the affected arm or leg Do not put too much pressure on the arm or leg: -do not cross legs while sitting -wear loose jewelry; wear clothes without tight bands -carry a handbag on the unaffected arm -do not use blood pressure cuffs on the affected arm -do not use elastic bandages or stockings with tight bands -do not sit in one position for more than 30 minutes Watch for signs of infection, such as redness, pain, heat, swelling, fever. Call the doctor immediately if any of these signs appear. Do exercises regularly to improve drainage. Keep regular follow-up appointments with the doctor. Check all areas of the arms and legs every day for signs of problems: -measure around the arm or leg periodically or if the limb seems swollen -use a tape measure at two consistent places on the arm or leg -tell the doctor if the limb suddenly gets larger The arm or leg may be less sensitive. Use the unaffected limb to test temperatures for bath water or cooking. Eat a well-balanced diet. Lymphedema is treated by mechanical methods and with medication. Mechanical methods include raising the arm or leg, wearing custom-fitted clothes that apply controlled pressure, cleaning the skin carefully to prevent infection, and controlling body weight. When used, pressure garments should cover the entire area of edema. For example, a stocking that only reaches the knee can become tight and cause problems if there is edema in the thigh. Pumps on the arm and leg that give intermittent pressure are very helpful. The cuff is inflated and deflated according to a controlled time cycle. This increases fluid flow in the veins and lymphatic vessels and keeps fluid from collecting in the arm or leg. Antibiotics may be used to treat and prevent infections. Other types of drugs such as diuretics or anticoagulants are generally not helpful, and may even worsen the problem. Finding the exact cause of the swelling and treating it correctly is important. Edema often leads to infection, which then increases protein deposits in the tissues. If an infection is diagnosed, appropriate antibiotics should be given. Blood clots should be ruled out, since massage and therapy to encourage drainage may make the clots more dangerous. If blood clots are found, they should be treated with medication. Coumarin was once used in some foods and medications in the United States. Coumarin was found to cause liver damage, and its use in foods and drugs in the United States has been banned since the 1950's. Coumarin has been studied to determine if it is effective in reducing the swelling caused by lymphedema. Research has not shown coumarin to be an effective treatment for lymphedema and has shown that it may cause liver damage. Coumarin is available in some countries, but has not been approved for use in the United States. Because lymphedema is disfiguring and sometimes painful and disabling, it can create mental, physical, and sexual problems. Women who develop lymphedema after treatment for breast cancer have more mental, physical, and sexual difficulties than women who do not develop lymphedema. The added stresses associated with lymphedema may interfere with its treatment that is often painful, difficult, and time-consuming. Coping with lymphedema in the upper body after breast cancer treatment is especially difficult for patients who have little social support. Some patients may react to the problem by withdrawing. It is also difficult for patients with painful lymphedema. Patients with lymphedema may be helped by group and individual counseling that provides information about ways to prevent lymphedema, the role of diet and exercise, advice for picking comfortable and flattering clothes, as well as emotional support. Surgery for lymphedema usually results in complications and is seldom recommended to the cancer patient. A rare but fatal complication of lymphedema is lymphangiosarcoma, a tumor of the lymphatic vessels. The average time between mastectomy and the appearance of lymphangiosarcoma is about 10 years. After a patient develops lymphangiosarcoma, the average survival time is 1.3 years. The cause of lymphangiosarcoma is not known. It appears as one or more bluish- red bumps on the affected arm or leg. First, one purple-red, slightly raised area in the skin of the arm or leg appears. The patient usually describes it as a bruise. Later, more tumors appear, and the bumps grow. Death usually results from metastases to the lungs. TO LEARN MORE For more information, call the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. The call is free and a trained information specialist is available to answer your questions. There are many other places to get information about cancer treatment and services. Check the social service office at your hospital for local and national agencies that can help with finances, getting to and from treatment, care at home, and dealing with other problems. Write to the National Cancer Institute at this address: National Cancer Institute Building 31, Room 10A24 9000 Rockville Pike Bethesda, MD 20892 Rasmussen JC, Kwon S, Sevick-Muraca EM, Cormier JN. Source Center for Molecular Imaging, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, 1825 Pressler St, SRB 330F, Houston, TX, 77030, USA, john.rasmussen@uth.tmc.edu. Abstract The lymphatic system is the secondary circulatory system responsible for fluid homeostasis and protein transport in the body. In addition, because the lymphatic system provides a primary pathway for cancer metastasis, lymph node involvement is routinely used as a determinant in cancer staging. Despite their importance, the lymphatics remain poorly understood, in part because of the historic lack of imaging modalities with sufficient spatial and/or temporal resolution to visualize the fine lymphatic structure and subtle contractile function. In recent years, near-infrared fluorescence (NIRF) imaging has emerged as a new imaging modality to non-invasively visualize the lymphatics and assess contractile lymphatic function in humans following administration of microdose amounts of a NIRF contrast agent. In this contribution, we first review NIRF imaging and its clinical application in sentinel lymph node mapping, intraoperative guidance, and assessing the architecture and contractile function of the lymphatics in health and in cancer-related lymphedema. We then present recent NIRF lymphatic imaging for non-invasive assessment of lymphatics both in preclinical melanoma models and in human subjects with melanoma. Deng J, Ridner SH, Murphy BA, Dietrich MS. Source School of Nursing, Vanderbilt University, 461 21st Ave. South, 600B Godchaux Hall, Nashville, TN, 37240, USA, jie.deng@vanderbilt.edu. Keywords: Secondary lymphedema – Head and neck cancer (HNC) – Symptom assessment – Instrument development – Late effect Abstract PURPOSE: Currently, no instruments are available to assess symptoms secondary to lymphedema in patients with head and neck cancer (HNC). The study aim was to develop and conduct preliminary tests of such an instrument. METHODS: A preliminary item pool was generated from a literature review, previous work in breast cancer-related lymphedema, and an observational study. The item pool was revised based on an expert panel's suggestions and feedback from 18 patients with HNC. The current questionnaire, the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N), was then pilot tested in 30 patients with HNC. RESULTS: Preliminary testing (1) demonstrated feasibility, readability, and ease of use of the LSIDS-H&N and (2) identified that there was a considerable level of symptom burden in the cohort of patients in the piloting sample. CONCLUSION: Content validity of the LSIDS-H&N was supported by the expert panel during development of the LSIDS-H&N. Further testing is ongoing. Finnane A, Liu Y, Battistutta D, Janda M, Hayes SC. Source School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia. anna.finnane@qut.edu.au Abstract OBJECTIVES: The purpose of this study was to describe the use, as well as perceived effectiveness, of mainstream and complementary and alternative medicine (CAM) therapies in the treatment of lymphedema following breast or gynecological cancer. Further, the study assessed the relationship between the characteristics of lymphedema (including type, severity, stability, and duration), and the use of CAM and/or mainstream treatment. METHODS: This was a cross-sectional study using a convenience sample of women with lymphedema following breast and gynecological cancers. A self-administered questionnaire was sent to 247 potentially eligible women. Of those returned (50%), 23 were ineligible and 6 were excluded due to level of missing data. RESULTS: In the previous 12 months, the majority of women (90%) had used mainstream treatments to treat their lymphedema, with massage being the most commonly used (86%). One (1) in 2 women had used CAM to treat their lymphedema, and 98% of those using CAM were also using mainstream treatments. Over 27 types of CAM were reported, with use of a chi machine, vitamin E supplements, yoga, and meditation being the most commonly reported forms. The perceived effectiveness ratings (1-7 with 7=completely effective) of mainstream (mean±standard deviation (SD): 5.3±1.5) and CAM therapies (mean±SD: 5.2+1.6) were considered high. CONCLUSIONS: These results demonstrate that mainstream and CAM treatment use is common, varied, and considered to be effective among women with lymphedema following breast or gynecological cancer. Furthermore, it highlights the immediate need for larger prospective studies assessing the inter-relationship between the use of mainstream and CAM therapies for treatment success. The good news is that there are nearly two million breast cancer survivors in the United States , and survival rates continue to increase for patients with this disease. But the flip side is that survival can present its own set of little-known complications. Researchers found that slightly more than half of 580 women diagnosed with breast cancer in one study experienced swelling, or lymphedema, in their arms or hands after the surgical removal of the breast or the tumor. This swelling was persistent among nearly one-third of the women. Women with lymphedema reported their quality of life as lower than did women without the problem. “Women don't know about lymphedema,” said Electra Paskett, the study's lead author and a professor of epidemiology and biostatistics in the School of Public Health at Ohio State University. For most women, the swelling takes place on the same side of the body as the affected breast. And it's generally not a sign of cancer's recurrence, Paskett said. Lymphedema can be painful, as the arm becomes fluid-filled, heavy and stiff and the skin becomes tight. Affected patients may have problems using their arms or hands. They also often need to buy clothes that are otherwise too big in order to fit the swollen limb. Lymphedema is caused by a build-up of lymphatic fluid. The lymphatic system serves as a source of immune cells and includes organs and tissues such as bone marrow, the spleen, and lymph nodes. Lymph nodes are small, round masses of tissue that filter lymphatic fluid and can also trap cancer or bacteria cells that flow through the blood. Removing or sampling the lymph nodes during surgery is fairly common, as they can serve as a conduit by which cancer can spread throughout the body. Both lymph node removal and radiation can disrupt the flow of lymph fluid. “The lymph system is like a freeway,” Paskett said. “If there is construction or a wreck, all of the cars back up. That's sort of what happens with lymphedema – there is a traffic jam, and the fluid gathers in the arm, hand and fingers.” Cervical cancer, breast, ovarian cancer Secondary Lymphedema in the cancer patient Hodgkins Disease or Hodgkins Lymphoma Leg Lymphedema Gynecological Cancer Lymphedema Affect Quality of Life Angiosarcoma and Long Term Lymphedema Head and Neck Swelling After Cancer Lymphedema After Cancer - How Serious Is It Secondary Lymphedema in the Cancer Patient Complications of Breast Cancer Radiotherapy Arm and Leg Swelling After Merkel Cell Cancer Merkel Cell Cancer - Blogspot.com by Pat O'Connor Cancer Associated with Lymphedema Preventing Arm Swelling after Breast Cancer, Surgery and Radiation University of Iowa Hospitals and Clinics Cancer Topics - National Cancer Institute ACOR.ORG - Association of Cancer Online Resources Your Body After Cancer Treatment Cancer - Medline Plus Information and Links Page Cancer Information on the Internet The Cancer Information Network Contact: Updated Jan. 10, 2012
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Kako dijagnosticirati Limfedem Dijagnosticiranje Limfedem Važna pitanja za pitajte svog Out Patient njihovih obitelji Povijest Razumjeti pacijente osobne medicinske povijesti KADA LIMFEDEM I SPREMIŠTE CONNIE M. SARVIS, RN, BN, MN, CON (C) CONNIE SARVIS je rana konzultant na Seven Oaks General Hospital in Winnipeg, Manitoba, Kanada. Ključne riječi: limfedem, lymphangitis, tromboza dubokih vena, filariasis, lymphoscintigraphy, Kaposi-Stemmer je znak, decongestive limfedem terapija, manualna limfna drenaža Ova disfiguring i ponekad bolno stanje utječe na mnogim pacijentima raka, i svibanj pojaviti mjeseci nakon operacije ili druge štete na limfni sustav. Prevencija i edukacija pacijenta posebno su važne za pacijente na rizik. Limfedem je uvjet da odražava disheartening realnost za mnoge pacijentima raka i drugih pacijenata, kao i. Simptomi uključuju oticanje, udovi i do dva puta na normal size, kože da uvlake i ostaje na taj način kada se pritisne (pitting), a thickening, hladna i Zamračivanje od kože (brawniness) .1 Visokim sadržajem proteina i limfna koji uzrokuje oticanje je idealno okruženje za dermatitis. The otekline i infekcije mogu postati i onemogućavanje disfiguring, izazivanje značajne fizičke i psihosocijalne oštećenje. Teško je precizno označavanje i učestalost limfedem zbog varijacije u svojoj definiciji i measurement.1 Jedna nedavna pregled izvijestili da limfedem, ruka pojavljuje u 26% pacijenata koji karcinom dojke therapy.2 To ne začuđuje, s obzirom da je limfna sustav je glavni put za metastaziranje. Limfedem, međutim, nije ograničena na karcinom dojke. Tretiraju pojedince za melanomas ili raka, jajnici, testisi, stidnica, ili mjehura može razviti sve limfedem.3 Limfedem također može pojaviti zbog venous bolest, nepokretnost, infekcija i drugih trauma, uključujući i sve veći broj joint replacement venous žetvu i postupci .3 Kao medicinska sestra, vaše vještine u upravljanju lymphedema može učiniti mnogo kako bi sačuvali kvalitetu života tih bolesnika. Zašto je kritična sustav break down Normalno, limfna sustav prikuplja višak tekućine i proteina iz tkiva i tijelo im se seli nazad u bloodstream po stopi od oko tri litre po day.4 Lymph je tjera-moving protiv gravitacije-kroz limfna žila po disanja i pokreta skeletni mišić kontrakcija u kojima se stvara gradijent tlaka. Niz ventili zadržati limfna teče u jednom smjeru. Kada se limfna sustav pati od neke vrsta trauma, ovu mogućnost da biste uklonili višak tekućine je ugrožena, limfna akumulira u interstitial prostore, najčešće u potkožnim masnim tkivima i time uzrokuje oticanje u ruku i nogu, i, manje često, u prtljažniku ili genitals.5 ustajao, protein-bogate limfne kanale tkiva uzrokuje povećanje u veličini i broju, što smanjuje raspoloživost kisika, umiješati se sa zacjeljivanje rana, i stvara optimalno okruženje za bakterijske infekcije (lymphangitis). Limfedem svibanj biti primarni ili sekundarni. Primarni limfedem je rijetka, naslijedila stanje u kojem se limfni čvorovi su ili odsutne ili nenormalan. Sekundarni limfedem rezultate iz oštećenja na limfna sustav-obično iz kirurško uklanjanje limfni čvorovi (koja je često potrebno u pacijentima raka) ili blockages u limfna sustava uzrokovana infekcija, raka, koji je putovao na limfni čvorovi, ili ožiljak tkiva (npr. , Od zračenja terapija, povrede, operacije ili da se ukloniti tumor) ,1 Lymphedema svibanj isto tako biti nuspojava od karcinoma dojke droga citrate tamoksifen (Nolvadex), jer to može uzrokovati krv clots i kasniji tromboza dubokih vena (DVT) da napredak na lymphedema.5 U nekim zemljama trećeg svijeta, najčešći uzrok lymphedema je filariasis, bolesti uzrokovane parazitski crvi Wucheria bancrofti, Brugia malayi i Brugia timori, koji je prenošen putem mosquitoes.6, 7 Lymphedema: Transient ili kronični Secondary lymphedema svibanj biti prelazni ili chronic.1 Transient lymphedema traje manje od šest mjeseci. Kože uvlake kada prešanih i razvedene ostaje bez brawniness.8 čimbenika koji pridobiti bolesnike na prelazni limfedem uključuju kirurški izlučivanje da leak proteina u kirurški site; upala sljedeće ozljede, zračenja, ili infekcija koja vodi do povećanog permeabilnost kapilara; limb nepokretnost da rezultate u smanjen compression od limfna sustav po musculature; privremenog gubitka limfne žile funkcija zbog operacije; i blokada u vein od loptica ili inflammation.1 Kronični limfedem je teško preokrenuti. Ona nastaje kao posljedica tumora ili povratak migracija u limfni čvorovi, infekcija ili ozljeda limfne žile, duga razdoblja nepokretnost, ili terapija zračenja ili operacije koje štete limfnog sustava. Radijacijska terapija može oštetiti inače zdrave limfni čvorovi i posuđe, što uzrokuje scar tissue to form, blokiranje normalna toka limfne tijekom limfna sustav. Kronični limfedem svibanj isto tako pojaviti nakon prethodno neuspješne upravljanje ranim lymphedema ili kada se vene je blokirana od strane krv grušati. Zoom in tih točaka u povijesti-uzimanje Zbog određenih kriterija za dijagnosticiranje limfedem još ne postoje, je temeljita medicinska povijest i fizički ispita neophodni su za diferencirane diagnosis.1 Age of napad će razlikovati primarni od sekundarni limfedem jer rano napad je više vjerojatno da će biti zbog jednog alteration u gena za vaskularne endotelne rast factor.3, Za 7 definitivnog dijagnoza primarnog lymphedema, uzroke sekundarne lymphedema prvo mora biti vladali van. Od sekundarni limfedem sklon rezultat od uzročan događaj kao što je kirurgija ili radijacijske terapije, morat ćete zamoliti detaljnijih pitanja u vezi bilo kakve prošlosti ambulantom i poslijeoperacijske komplikacije, posebno da li je za operacije raka i da li bilo koje limfni čvorovi su uklonjene. Rapid napad of lymphedema svibanj ukazuju na tumor infiltration ili blokiranje od glavnih limfna staza. Povijest bi trebala dokument bilo koje ograničenje pokretljivosti, kao što su korištenje invalidskih kolica; traume (osobito na noge, abdomen, ili genitalija regiji); i boravka u ili posjeta trećim zemljama svijeta (zbog rizika od filariasis). Zamolite bolesnika da li su kronični venous nedostatnost, disfunkcija štitnjače, artritis, ili hipertenzija, jer svaki od tih uvjeta može uzrokovati venous edem. Važno je razlikovati lymphedema iz edem povezane s venous insufficiency.5 Lymphoscintigraphy je test koji može pomoći da razlika s. U ovom postupku, malu količinu radioaktivnog protein dye je injected u web prostor između prvog i drugog broja je zahvaćena limb, limb je tada snimljeno s gama kamera promatrati na obojeni kao što se miče kroz limfna system.9 Slike prikazuju dye izvan limfna strukture predlažemo edem, limfna podrijetla. Kompjutorska tomografija (CT) i magnetska rezonancija (MRI), također se mogu koristiti za dijagnozu limfedem.9 Međutim, ove oblike imaging, kao i lymphoscintigraphy, mogu biti skupi. Fizikalni nalaz da sugeriše limfedem U vaše fizičko procjeni, ispitati koži zahvaćeni ekstremitet (s). Dryness, povećana debljina, hyperkeratosis (skaliranje), lymphangiomas (blisters sadrže limfna tekućina), abnormally topla ili vruća temperatura, neobično tamne kože, i prisustvo bilo koje nodules su svi pokazatelji limfedem.3 Papillomatosis-a cobblestone izgleda kože-svibanj isto tako biti prisutna, ona rezultate iz dilatirane i distended limfna žila u enveloped da su fibrotic tissue.9 Pogledajte, također, za Kaposi-Stemmer's registracije nemogućnosti patiti fold jedan od kože na osnovni je drugi nožni prst jer koža je tako obložen-koji pokazuje na jedan dijagnoza limfedem.9 Pobrinite se da primjetite bilo kakve rane na koži. Pacijenti s limfedem svibanj imati lymphorrhea, plačući i limfna tekućina, koja svibanj biti dovoljno bogat da zapravo pokrenuti ili kapanje niz nogu. Ovaj simptom predisposes pacijenata cellulitis. Limfedem može uzrokovati senzacija limb of heaviness i stezanje kože, topline ili požara, ili "igle i igle." Neki pacijenti imaju iskustvo umjerena do teškog bola zbog nerve compression iz okolnih edematous tissue.10 živaca compression svibanj i smanjiti odgovor na poticanje i pridobiti bolesnike na ozljede i infekcije. Vaša procjena fizičke potrebe uključiti detalje o stupnju oteklina, i oblika i veličina, u limb (s) zahvaćene, bolesnik je visina i težina (i body mass index, ako je dostupno); funkcionalnosti u limb, a arterijska ovlasti . Ako limfedem je jednostrana, quantifying opseg oteklina se usporedbom veličine jedan pogođeni limb za zdrav može biti korisna za qualifying i težini bolesti. Budite svjesni, ipak, da normalni anatomski varijacije mogu otežavati stvari, i da je usporedba neće biti moguće ako oba su zahvaćeni udovi. Ako je zahvaćena limb je   20% veća od nepromijenjen one.11 Mehanička tehnike su temeljne terapija Za bolesnika s umjerenim do teškim lymphedema, decongestive lymphedema terapija (DLT) 11 je standardni tretman. Njezina je svrha pomoći mobilizirati limfna i trošiti fibrosclerotic tkiva. U početno liječenje faza, DLT se sastoji od ručne limfne drenaže (MLD), compression, savjestan higijenu kože kako bi spriječio infekcije, i exercise.12-14 To je obično nakon koje je uslijedilo održavanja program se sastoji od kompresije, njegu kože, i vježbe. Ako lymphedema je blaga do umjerena, DLT svibanj biti bypassed u korist održavanja terapija. Imajte na umu da iako je nadmorska visina je temeljni tretman za edem of venous podrijetla, ne pojavljuju se kao učinkovit za liječenje lymphedema.15 Međutim, nadmorska visina svibanj biti korisni kao dodatak na komponente DLT, opisanog dolje. Drug terapiju i operacije su također raspravlja, ali su ograničene use.16 • ručna limfna drenaža je svjetlo-masažna terapija pritisak dizajnirana za poticanje limfe potičući otvaranje i zatvaranje ventila, u limfne kapilare i posuđe. Smjeru masaža je protiv gravitacije, od distalni na proksimalni dio u limb. Tijekom masaže-a session obično traje 30 - 60 minuta-pacijenta obično nosi svjetlo compression odijelu ili visoka da zadrži pritisak na tkivo i spriječiti protok limfna natrag u interstitial spaces.16 Idealno, ovaj terapija bi trebao biti pod upravom je certificirani terapeut limfedem. MLD treba izbjegavati u bolesnika s određenim uvjetima, kao što je pacijente koji su iskusni kardiovaskularne kvara ili u kojima DVT je sumnjiva, jer će sila više tekućine prema srcu i svibanj protjerati krv clots.16 MLD, međutim, neće predstavljati rizika u bolesnika s arterijska kompromis (dakle, nema impulsa u noge, slabije prokrvljeni, dijabetes, itd.). • kompresija služi dvojno svrhu optimiziranja akcije na mišiće kao limfna pumpe i spriječava daljnje oteklina. Bez obzira da li su bolesnici primaju početno liječenje faza DLT ili održavanje terapija, arterijska nadležnosti treba da se procijeni s Doppler ultrazvuk prije pomoću kompresije. Prije nego što odluči da oblog zahvaćeni ekstremitet, nekoliko drugih faktora treba da se smatra, kako je dobro. Kompresija može pogoršati stanje siromaha kože, DVT, srce uvjetima, upala, a cellulitis, svibanj je također povećati rizik od infection.16 Istovremeno, limfedem sama stvara teren za uzgoj infekcije-koji je uvjerljiv razlog za korištenje kompresije . Studije su pokazala da višeslojni sustavi smanjuju lymphedema učinkovitije od jednoslojan compression haljine ako se koristi za početno faza treatment.17 višeznačnom compression sustavi sastoje se od tri ili četiri razine bandaging i koriste se u prva dva do tri tjedna od početnih faza treatment.3 povez višeslojni sustavi mogu biti ostavljena na sedam dana u isto vrijeme prije mijenjanja ili su promijenila dva do tri puta tjedno, ako je rana skrb required.18 Pneumatska kompresije pumpe se sastoje od jednostavnih, multichamber rukavu koja odgovara preko zahvaćeni ekstremitet. The komore naizmjence napuhati i umanjiti u skladu s vremenski ciklus, izaziva peristaltic gibanje na swollen tkiva. Njihovo korištenje za kontrolu lymphedema, međutim, je controversial.15 Compression-haljine, kao što su stockings, rukavima, i rukavice-trebali bi se koristiti samo u održavanje therapy.3 su dostupni s polica u malim, srednjim i velikim veličinama, ili mogu biti prilagođeni-made za pacijenta. Haljine su ocijenjeno da dostavi 30 - 60 mm Hg, pressure.19 Pacijenti trošenje odijela za većinu dana i ukloniti ih noću provjeriti, čisto, i moisturize kože. Provjerite je li vaš pacijent ima alergiju na odijelu komponente, kao što je latex. • gadljiv njegu kože je kritična komponenta lymphedema tretman. Visokim sadržajem proteina i limfna tekućina predisposes pacijenata infekcije u lymphedematous limb.20 A dnevnu rutinu bi trebao biti uspostavljen u kojima je zahvaćena limb je obavila očevid za rane, čiste, i moisturized. Rutinske svibanj mijenjati se da svaka dva ili tri dana, tjedno ili u pacijenata koji bi mogao imati koristi od kontinuiranog višeslojni kompresije i čija koža je u relativno dobrom stanju. Oprezno inspekcija je posebno važno ako ima senzorska neuropatija. Nakon čišćenja kože s blagim hypoallergenic sapun i voda, pacijenta treba primjenjivati jedan ublažavajući, po mogućnosti u večernjim satima, za rehydration noćenje. Losione koji sadrže lanolin ili mirisa treba izbjegavati jer one mogu uzrokovati aktivacija s rezultiralo dermatitis. Osim toga, izbjeći petrolatum-based losione, jer oni svibanj oštećenja compression haljine. Prsti i stopala također treba pregledati redovito za gljivične infekcije, što je vrlo čest u pacijenata koji imaju lymphedema. • Tjelovježba može pomoći promovirati limfe i povećati protein reapsorpcija kao rezultat mišića contraction.9, 21, vježbe, međutim, treba biti nježan i odgovara na individualnoj sposobnosti i fitness razini. Snažan sportski se ne preporuča zbog mogućnost trauma.17 • Drug-terapije, osim antibiotika prema infekcija uzrokovanih limfedem-nije bio vrlo koristan u liječenju limfedem direktno. Diuretics pomoći da purge vaskularne fluid, ali oni su u nedjelotvornim kliring iz viška proteina i mogu uzrokovati vezivno tkivo fibrosis.22 Stoga, diuretics ne smije se koristiti, osim ako postoje dokazi od prekomjerne venous fluid.22 Do limfedem može biti riješen, bol može se upravljati s non-opioidni analgetici, tehnike relaksacije, blage do jake opioidni analgetici, lijekovi i pomoćno-npr., amitriptyline HCL (Elavil, Endep, dr.), ili kroskožna električni nervni stimulation.1 • Kirurgija je rezervirana za grubog edematous udovi na de-skupno neke od tkiva. Rezultati su raznolika, međutim, i konzervativne tretman je još uvijek potrebna za upravljanje preostalih limfedem.22 Nadalje, kirurški zahvati na bilo koji lymphedematous limb mogu predstaviti i teškim kroničnim zacjeljivanje rana problema. Edukacija i pomoć su odlučujuće U limfedem, dvije dodatne dimenzije Njega ne treba previdjeti: Edukacija i psihosocijalnog zdravlja. Edukacija je kritično i za prevenciju i upravljanje lymphedema-posebno za rak patients.23 Klinicara je potrebno educirati pacijente o rizik od razviti limfedem nakon operacije ili zračenja terapija, kako prepoznati simptome limfedem rano, i kako upravljati uređajem. Trebat će vam savjetovati bolesnika, na primjer, da nose loose-uklapanje odjeće, a ne na križ njihove noge dok sjedi, i da bi se izbjegla sjediti u jednom položaju za više od 30 minuta. Također je izuzetno važno kako bi se ocijenilo i psihosocijalne učinke limfedem. Stanje može uzrokovati smetnje i glavni unakaženje-prepreka da pacijentima raka, ili preživjeli su često bolestan-opremljeni da prevlada. Pacijenti koji doživljaj boli od stanja izvješće higher levels of body image poremećaj i smanjen spolni drive.24 The dodano teret težačkog, dugo trajati tretmani za limfedem mogu dalje nasrnuti pacijenta, već krhke psihe. Psihosocijalna pitanja svibanj biti upućeno od strane pojedinca ili grupe savjetovanje, zajedno s praktičnim informacijama o prehrani i vježbe, te savjete za branje flattering odjeća i udobna. Vaša nastojanja da se skrb za pacijente koji imaju ili su rizične za-limfedem može učiniti mnogo dobra. To je istinita ne samo kada je riječ o pacijentima 'fizički oporavak, ali kada je riječ o njihovu psihološku dobrobit, kako je dobro. Sada možete prevesti bilo koju stranicu na našoj web stranici pomoću Google translator na našu početnu stranicu: Lymphedema People http://www.lymphedemapeople.com Pat O'Connor Osnivač i Izvršnog Administrator Statistics: Posted by patoco — Mon Jul 14, 2008 10:55 pm