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Secondary Lymphedema in the cancer patient MedSurg Nursing, Oct, 2006 by Jane E. Lacovara, Linda H. Yoder October is Breast Cancer Awareness Month, and nurses should engage in all the prevention, treatment, and survivorship education and related activities that take place during the month. Nurses play a vital role when interfacing with breast cancer survivors. Medical-surgical nurses may interact with these individuals when they need care for non-oncology problems. It is important to describe a serious problem encountered by many breast cancer survivors--lymphedema. Lymphedema is a quality-of-life, non-fatal condition that receives less funding for research than other pathologies, yet it affects a large number of people. Actual numbers are hard to assess with ranges of 15%-25%(35-40% according to more recent studies) in the breast cancer population alone. This does not include patients with melanoma or other surgical patients who are at risk for developing lymphedema. Perhaps 2 million cancer survivors or up to 400,000 patients cope with lymphedema daily (Petrek, Pressman, & Smith, 2000). The pathophysiology, etiology, stages, treatment, prevention, and nursing implications of lymphedema will be discussed in this column. "Lymphedema is the accumulation of protein-rich interstitial fluid within the skin and subcutaneous tissue that causes chronic inflammation and reactive fibrosis of the affected tissues" (Wyatt & Pribaz, 2004, p. 817). Normally, lymph fluid is drained from the cells in the body and carried in the lymphatic system. Lymph is cleared through a network of thin-walled lymphatics, which cross the axillary nodal basin and ultimately empty into the venous system. The lymphatic system is part of the immune system, which carries lymphocytes throughout the body to respond to antigens and communicate responses to other parts of the body. The lymphatic system also carries excess fluid back to the venous bloodstream through a series of ducts or tubules, and empties excess fluid near the subclavian vein. Lymphedema occurs when the lymphatic ducts become blocked and a buildup of lymph fluid occurs in the fatty tissues just under the skin, resulting in swelling (Lymphedema, 2004). The ability of the medical-surgical nurse to recognize lymphedema and facilitate early treatment of this common side effect of breast cancer therapy will improve patient outcomes and quality of life (Sammarco, 2004). Pathophysiology of Lymphedema The lymph fluid passes through the lymph nodes, which are found in the articulations of the large joints, the mesentery system, and the neck. A healthy adult has approximately 600-700 lymph nodes. The nodes act as filters to remove waste and help to regulate protein content in the lymph fluid. The lymph fluid is carried through long tubules called lymph ducts, which eventually empty the fluid into deeper and larger vessels called trunks. All the lymph trunks empty into either the thoracic duct or the right lymphatic duct. The thoracic duct drains the left arm, both legs, and three-fourths of the trunk of the body. The right lymphatic trunk drains the right arm and the remaining one-fourth of the trunk. The location of the surgery, tumor, or radiation therapy will predict whether or not the patient develops secondary lymphedema and how severe the lymphedema will be (Penzer, 2003). Lymphedema results from either a mechanical or dynamic insufficiency in the lymphatic system or a combination of these conditions. In a dynamic insufficiency, the lymph flow actually exceeds the transport capability of the intact lymphatic system. Usually this type of lymphedema has a genetic etiology. This dynamic insufficiency causes primary lymphedema. In a mechanical insufficiency, an injury to the lymphatic system impairs the lymph flow due to paralysis, blockage, or inadequacy of the lymphatic system after surgery, radiation therapy, infection, or tumors. This mechanical insufficiency causes secondary lymphedema, which is the most common type of lymphedema in the United States. Approximately 15%-20% of breast cancer patients develop lymphedema up to 20 years following treatment. With 2 million breast cancer survivors, this number translates into approximately 400,000 patients coping with lymphedema on a daily basis (Petrek et al., 2000). Primary Lymphedema Lymphedema is categorized as either primary or secondary based on the etiology. In primary lymphedema, some type of developmental abnormality exists in the lymphatic system. Congenital lymphedema accounts for 10%25% of all primary lymphedema cases, with females affected twice as often as males (Revis, 2005). Primary lymphedema may occur at any time in life; however, primary lymphedema is thought to be a genetically determined disease and may present at birth or shortly thereafter (Milroy disease), at puberty (referred to as lymphedema praecox), or after age 35 (lymphedema tarda) (Wyatt & Pribaz, 2004). Primary lymphedema usually affects the lower extremities (International Society of Lymphology, 2003). Secondary Lymphedema Secondary lymphedema is a result of some sort of an insult to the lymphatic system caused by an obstruction or a disruption that prevents the tubules from draining the fluid from the surrounding tissues. It may occur from infection caused by streptococci or filariasis (caused by a parasite), surgery, radiation therapy, or tumors. Lymphedema caused by infection must be treated with an antibiotic or antiparasitic agent (Petropoulos, 2005; Stedman, 2004). Secondary lymphedema may develop after surgery for malignant solid tumors, such as in breast cancer or lymphoma. It also may develop after an axillary node dissection, breast surgery, or after radiation treatments. Because surgery or radiation treatments are the most common cause of lymphedema in the United States, this type of lymphedema is the primary focus of this column. Although lymphedema may have different etiologies, the treatment for all types is the same. Stages of Lymphedema: Stages I, II, and III Stage I lymphedema is considered reversible. The lymphedema is pitting and the tissues are soft; the patient may or may not have an increased arm girth or feeling of upper-extremity heaviness. Elevating the affected area may reverse the edema. In Stage II, the lymphedema progresses and may become nonpitting and fibrotic. Stage II lymphedema is considered irreversible and elevation does not reduce swelling. In Stage Ill lymphedema, the tissues become hard and may have cartilage formation developing in the area. The swelling is severe and may form deep crevices. Stage III lymphedema is considered rare in patients with breast cancer (Harris, Hugi, Olivetto, & Levine, 2001). Diagnosing Lymphedema In 2004, the Oncology Nursing Society (ONS) described a cluster of symptoms that is unique to breast cancer survivors with lymphedema. The cluster of symptoms includes an altered sensation in the limb, fatigue, psychological distress, and decreased physical activity (Muscari-Lin & Ridner, 2004). Other symptoms of lymphedema include: * 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. Changes of sensation in an arm may be an early indication of lymphedema and should be thoroughly investigated (Amer, Radina, Porock, & Culbertson, 2003). Other causes of lymphedema include (a) metastasis or development of obstructive tumors, such as tumors of the axilla or brachial plexus; (b) lymphangiosarcoma; (c) infection; or (d) axillary vein thrombosis. Lymphoscintigraphy may be used to rule out a systemic cause of the lymphedema and may be used to predict who will develop lymphedema. Lymphoscintigraphy is 100% sensitive and specific for diagnosing lymphedema; however, it is expensive and may not be available at all facilities where medical surgical-nurses practice (Ferri, 2004). A simple assessment tool for the medical-surgical nurse is preoperative and post-surgical measurements of both arms. The circumference of the arms should be measured at several anatomical positions: (a) finger joints, (b) wrist, (c) 10 cm distal to the lateral epicondyles, and (d) 15 cm proximal to the lateral epicondyles. A difference of greater than 2 cm between the arms at any one of the four measurement points, as well as presence of the ONS cluster of symptoms described previously, may alert the nurse to lymphedema (Brown, 2004). If lymphedema is accompanied by redness and swelling, and an elevated WBC (>12,000/ml) or an elevated temperature (>38[degrees] C or >100.4[degrees] F), the cause may be cellulitis or a local infection rather than lymphedema, and must be treated with antibiotic therapy. Streptococcus Group A usually causes cellulitis, but staphylococcus aureus also may cause it. Treatment would consist of penicillin, dicloxacillin, amoxicillin, ticarcillin, methicillin, or vancomycin for a highly resistant bacteria strain (Gilbert, Moellering, Eliopoulos, & Sande, 2005). Cellulitis may occur concurrently in lymphedema because the pooling of protein-rich lymph fluid makes it easier for the patient to develop an infection. Before treating lymphedema, possible tumor involvement of the axilla or brachial plexus, cellulitis, or even deep vein thrombosis must be ruled out. All these conditions may cause edema of the extremities, which may be misdiagnosed as lymphedema. Treatment of Lymphedema The literature is limited in regard to scientifically proven lymphedema treatments because of the lack of prospective, randomized clinical trials that accurately control all variables and measure the amount of lymphedema present. Little rigorous science supports recommendations; however, several professional organizations have guidelines or recommendations (Lacovara, 2006). Compression garments (elastic sleeves) that deliver 20-60 mm Hg of pressure are used for treating lymphedema. A prospective study by Collins, Mortimer, D'Ettore, Ahern, and Moscovic (1995) demonstrated significant decreases in lymphedema in 27 women using the garments. CT exams were used to compare unaffected arms with lymphedema arms using compression for 1, 3, and 12 weeks of treatment (Collins, Mortimer, D'Ettore, Ahern, & Moscovic, 1995). High-quality compression garments are custom made and should be fitted by properly trained personnel. The practice guidelines of the Canadian Medical Association (CMA) encourage the long-term, consistent use of compression garments when lymphedema occurs. The garments last for approximately 4-6 months depending on how often they are worn and how well they maintain their elasticity. Recommendations about how long to wear the fitted sleeves vary from only during working hours to 24 hours a day. The CMA also provides practical advice regarding skin care, exercise, and weight control (Harris et al., 2001). Massage and physical therapies have been used with variable effectiveness in treating lymphedema. Complex decongestive physiotherapy includes manual lymph drainage, bandaging garments such as elastic wraps, and exercises. Complex decongestive physiotherapy requires further evaluation in randomized trials (Harris et al., 2001). This therapy usually is performed by physical therapists who specialize in lymphedema treatment, and some rehabilitation centers offer this specialty treatment (Foldi, 1994). The Foldi two-phase approach of intensive skin care, exercise, massage, and compression bandaging has been used widely in the United Kingdom (UK) as a gold standard (Badger, Peacock, & Mortimer, 2000). Currently, the position paper of the International Society of Lymphology recommends complex physiotherapy by a physician, nurse, or physical therapist who has been professionally trained. It should be noted that compression bandaging, if done incorrectly, may be harmful or useless. Complex physiotherapy treatment consists of two phases. The first phase involves preventive skin care, light manual massage, range-of-motion exercises, and compression with multilayer wrapping. The second phase, which must be initiated promptly after phase one, includes use of a compression sleeve, remedial exercise, and repeated light massage as needed (International Society of Lymphology, 2003). At the Breast Cancer Clinic of the Arizona Cancer Center, patients are advised to wear the compression sleeve prophylactically when flying because pressure changes may trigger lymphedema (NLN Advisory Committee, 2004). Pneumatic compression devices have been used for treating lymphedema, but insufficient evidence exists to support or reject this treatment. In addition, these devices are expensive and are contraindicated in cases of cellulitis or deep vein thrombosis. These devices are not recommended by any of the professional organizations cited in this column. Prevention: Sentinel Node Biopsy The advent of sentinel node biopsy (SNB) should lead to decreased incidence of lymphedema. This newer procedure has changed the way axillary lymph nodes have been evaluated for the last 100 years. The procedure used in the past, known as complete axillary node dissection, removed a large number of lymph nodes and caused about 20% of patients to develop lymphedema. In sentinel node biopsy, a blue dye is injected in the area of the breast tumor and the dye is traced to the first few axillary nodes that drain the breast area. This "blue" node is then checked for malignancy and if it is cancer free it is not removed. Even if the sentinel node is removed along with other "blue" nodes, in many cases fewer nodes are removed than in cases that require complete axillary node dissection (McCarthy, 2003). Sentinel lymph node removal is better than complete axillary lymph node dissection with regard to lymphedema, range of motion, quality of life, and sensory loss for clinically node-negative patients. More than 5,200 patients participated in the Axillary Lymphatic Mapping Against Nodal Axillary Clearance randomized multi-center trial (ALMANAC) in the United Kingdom. Results were presented at the San Antonio Breast Conference in 2005 (Fleissig et al., 2006). This study provided the first long-term quality-of-life results from a randomized trial comparing SNB with standard treatment. Results demonstrated that SNB is associated with less arm morbidity and better quality of life than standard axillary treatment. Consequently, every oncology surgeon in the United Kingdom is currently being trained in SNB. It is currently the gold standard in the United States and should be offered to all patients at the time of their surgery. Once the surgery has been performed, the lymphatic pathways may be disrupted and so SNB cannot be performed later or after the surgery. Prevention and Ongoing Care: Nursing Implications Because breast cancer survivors remain at life-long risk of developing lymphedema, prevention of lymphedema is a very important role for the medical-surgical nurse. Clearly, the prevention of lymphedema is much more effective than treating the problem after it occurs. The National Lymphedema Network (NLN) published a position statement that lists risk-reduction practices, such as proper skin care (avoiding injury, reducing infection risks), appropriate activity levels, avoidance of constrictive clothing, use of compression garments, avoidance of temperature extremes, and other suggestions (NLN Advisory Committee, 2005). This handout for breast cancer patients and others at risk for lymphedema may be accessed online (http://www.lymphnet.org The handout may be used by health care personnel in its entirety for educational purposes only. Recommendations in the NLN handout help nurses with ongoing prevention and assessment of problems such as cellulitis to keep patients functioning optimally. References Amer, J., Radina, M., Porock, D., & Culbertson, S. (2003). Predicting breast cancer-related lymphedema using self-reported symptoms. Nursing Research, 52, 370-379. Badger, C., Peacock, J., & Mortimer, P. (2000). Multilayer bandaging followed by compression hosiery was more effective than hosiery alone in reducing lymphedema of the limb. A clinically useful method for evaluating lymphedema. Clinical Journal of Oncology Nursing, 8, 3538. Collins C.D., Mortimer P.S., D'Ettore, H., Ahern, R., & Moscovic, E. (1995). Computed tomography in the assessment of response to limb compression in unilateral lymphedema. Clinical Radiology, 50(8), 541-544. Fleissig, A., Fallowfield, L, Langridge, C., Johnson, L., Newcombe, R., Dixon, J., et al. (2006). Post-operative arm morbidity and quality of life. Results of the ALMANAC randomized trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Research and Treatment, 95, 279-293. Ferri's best test: A practical guide to clinical laboratory and diagnostic imaging. St. Louis, MO: Elsevier. Treatment of lymphedema. Lymphology, 27, 1-5. Gilbert, D., Moellering, R., Eliopoulos, G., & Sande, M. (2005). The Sanford guide to antimicrobial therapy. Hyde Park, VT: Antimicrobial Therapy, Inc. Harris, S., Hugi, M., Olivetto, I., & Levine, M. (2001). Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema. Canadian Medical Association Journal, 64, 191199. International Society of Lymphology. Diagnosis and treatment of peripheral lymphedema: Consensus document of the International Society of Lymphology. Lymphology, 36, 84-91. Lacovara, J. (2006, January). Preventing secondary lymphedema in the cancer patient. Paper presented at the 37th Annual Focus on Women's Cancers, Tucson, AZ. Lymphedema. Patient education handout. RNConsult.com. Retrieved December 21, 2004, from http:// home.mdconsult.com McCarthy, A. (2003). Now what? Understanding a breast cancer diagnosis. Muscari-Lin, E., & Ridner, S. (2004). Lymphedema: Responding to our patient's needs. Presented at the 29th Annual Oncology Nursing Society Congress, Anaheim, CA. National Lymphoma Network (NLN) Advisory Committee. Position statement of the National Lymphedema Network. Topic: Air travel. Retrieved September 18, 2006, from http://www.lymphnet.org/position.html Lymphoedema. Nursing Standard, 17, 45-49. Petrek, J., Pressman, P., & Smith, R. (2000). Lymphedema: Current issues in research and management. Petropoulos, P. (2005). Lymphedema. In F. Ferri (Ed.), Clinical advisor. Philadelphia: Elsevier/Mosby. Lymphedema. Retrieved January 19, 2005, from http://www emedicine.com/med/topic2722.htm Sammarco, A. (2004). Enhancing the quality of life of survivors of breast cancer. Annals of Long Term Care, 12, 40-45. Stedman's medical dictionary. Baltimore, MD: Lippincott, Williams & Wilkins. Wyatt, L., & Pribaz, J. (2004). Lymphedema. In M. Abeloff, J. Armitage, J. Niederhuber, M. Kastan, & W.G. McKenna (Eds.), Clinical oncology (3rd ed) (pp. 817-831). Philadelphia: Elsevier/Churchill Livingstone. Jane E. Lacovara, MSN, RN-BC, CMSRN, CNS, is a Clinical Nurse Specialist, Surgery, University Medical Center, Tucson, AZ, and MEDSURG Nursing Editorial Board Member. Linda H. Yoder, PhD, MBA, RN, AOCN[R], FAAN, is Program Director, Evidence-Based Practice, Outcomes & Research, Adventist HealthCare, Rockville, MD. Note: This column is made possible through an educational grant from C-Change, a Washington, DC, based organization comprising the nation's key cancer leaders from government, business, and nonprofit sectors. These cancer leaders share the vision of a future where cancer is prevented, detected early, and cured or is managed successfully as a chronic illness. The mission of C-Change is to leverage the combined expertise and resources of its members to eliminate cancer as a (major) public health problem at the earliest possible time. C-Change is both a forum and a catalyst for identifying issues and major challenges facing the cancer community and for initiating collaborative actions to complement the efforts of individual C-Change members. Medical-Surgical nurses are invited to learn more about this important organization by visiting www.ndoc.org http://findarticles.com/p/articles/mi_m ... 15450/pg_1 Pat O'Connor Lymphedema People http://www.lymphedemapeople.com 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 beings. This swelling is called lymphedema. The swelling that occurs is permanent, and while it is not curable it is treatable. Permanent Leg or Arm Swelling ****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 are cancer 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. What is Lymphedema? 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. What are the symptoms of 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. How is Lymphedema Treated? The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), 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. What are some of the complications of lymphedema? 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 immuno-deficient. Draining wounds that leak lymphorrea 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. Can lymphedema be cured? 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 (c) 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.
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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