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Diagnosing Lymphedema by Physical Examination Important Questions to Ask Your Patient Out thier Family History Understand the patients personal medical history CONNIE M. SARVIS, RN, BN, MN, CON(C) CONNIE SARVIS is a wound consultant at Seven Oaks General Hospital in Winnipeg, Manitoba, Canada. KEY WORDS: lymphedema, lymphangitis, deep vein thrombosis, filariasis, lymphoscintigraphy, Kaposi-Stemmer's sign, decongestive lymphedema therapy, manual lymph drainage This disfiguring and sometimes painful condition affects many cancer patients, and may appear months after surgery or other damage to the lymph system. Prevention and patient education are especially important for patients at risk. Lymphedema is a condition that reflects a disheartening reality for many cancer patients—and other patients, as well. Symptoms include swelling of limbs up to twice the normal size, skin that indents and stays that way when pressed (pitting), and thickening, hardening and darkening of the skin (brawniness).1 The high protein content of the lymph that causes the swelling is an ideal environment for dermatitis. The swelling and infection can become disabling and disfiguring, causing significant physical and psychosocial impairment. It's hard to pinpoint the precise incidence of lymphedema because of variations in its definition and measurement.1 One recent review reported that lymphedema of the arm occurs in 26% of patients undergoing breast cancer therapy.2 This is not surprising, given that the lymphatic system is the primary route for metastasis. Lymphedema, though, is not limited to breast cancer. Individuals treated for melanomas or cancer of the ovaries, testicles, vulva, or bladder can all develop lymphedema.3 Lymphedema can also occur because of venous disease, immobility, infections, and other trauma, including an increasing number of joint replacement and venous harvesting procedures.3 As a nurse, your skill in managing lymphedema can do much to preserve the quality of life for these patients. Normally, the lymphatic system collects excess fluid and protein from body tissues and moves them back into the bloodstream at the rate of about three liters per day.4 Lymph is propelled—moving against gravity—through the lymphatic vessels by breathing movements and skeletal muscle contractions that create a pressure gradient. A series of valves keep lymph flowing in one direction. When the lymphatic system suffers some type of trauma, this ability to remove excess fluid is compromised; lymph accumulates in interstitial spaces, most commonly in subcutaneous fatty tissue, and thus causes swelling in the arms and legs, and, less frequently, in the trunk or genitals.5 Stagnant, protein-rich lymph causes tissue channels to increase in size and number, which reduces oxygen availability, interferes with wound healing, and creates an optimum environment for bacterial infection (lymphangitis). Lymphedema may be either primary or secondary. Primary (congenital) lymphedema is a rare, inherited condition in which the lymph nodes are either absent or abnormal. Secondary lymphedema results from damage to the lymphatic system—typically from surgical removal of lymph nodes (which is often necessary in cancer patients) or blockages in the lymphatic system caused by infection, cancer that has traveled to the lymph nodes, or scar tissue (e.g., from radiation therapy, an injury, or surgery to remove a tumor).1 Lymphedema may also be a side effect of the breast cancer drug tamoxifen citrate (Nolvadex), because it can cause blood clots and subsequent deep vein thrombosis (DVT) that advances to lymphedema.5 In some third world countries, the most common cause of lymphedema is filariasis, a disease caused by the parasitic worms Wucheria bancrofti, Brugia malayi, and Brugia timori, which is transmitted by mosquitoes.6,7 Secondary lymphedema may be transient or chronic.1 Transient lymphedema lasts less than six months. The skin indents when pressed and stays indented without brawniness.8 Factors that predispose patients to transient lymphedema include surgical drains that leak protein into the surgical site; inflammation following injury, radiation, or infection that leads to increased capillary permeability; limb immobility that results in decreased compression of the lymphatic system by the musculature; temporary loss of lymph vessel function due to surgery; and blockage in a vein from a clot or inflammation.1 Chronic lymphedema is difficult to reverse. It occurs as the result of tumor recurrence or migration into the lymph nodes, infection or injury to lymph vessels, long periods of immobility, or radiation therapy or surgery that damages the lymph system. Radiation therapy can damage otherwise healthy lymph nodes and vessels, which causes scar tissue to form, blocking the normal flow of lymph throughout the lymphatic system. Chronic lymphedema may also occur after previously unsuccessful management of early lymphedema or when a vein is blocked by a blood clot. Because specific criteria for diagnosing lymphedema do not yet exist, a thorough medical history and physical exam are essential for a differential diagnosis.1 Age of onset will differentiate primary from secondary lymphedema because early onset is more likely to be due to an alteration in the gene for vascular endothelial growth factor.3,7 For a definitive diagnosis of primary lymphedema, the causes of secondary lymphedema must first be ruled out. Since secondary lymphedema tends to result from a causative event such as surgery or radiation therapy, you'll need to ask detailed questions about any past surgeries and postoperative complications, especially whether the surgery was for cancer and whether any lymph nodes were removed. Rapid onset of lymphedema may indicate tumor infiltration or a blockage of a major lymphatic pathway. The history should also document any restrictions on mobility, such as wheelchair use; trauma (especially to the legs, abdomen, or genital region); and residence in or visits to third world countries (due to risk of filariasis). Ask patients whether they have chronic venous insufficiency, thyroid dysfunction, arthritis, or hypertension, because each of these conditions can cause venous edema. It's important to distinguish lymphedema from edema associated with venous insufficiency.5 Lymphoscintigraphy is a test that can help with that distinction. In this procedure, a small amount of radioactive protein dye is injected into the web space between the first and second digits of the affected limb; the limb is then photographed with a gamma camera to observe the dye as it moves through the lymphatic system.9 Images showing dye outside the lymphatic structures suggest edema of lymphatic origin. Computed tomography (CT) and magnetic resonance imaging (MRI) can also be used to diagnose lymphedema.9 However, these forms of imaging, as well as lymphoscintigraphy, can be costly. In your physical assessment, examine the skin of the affected limb(s). Dryness, increased thickness, hyperkeratosis (scaling), lymphangiomas (blisters containing lymph fluid), abnormally warm or hot temperature, unusually dark skin, and the presence of any nodules are all indicators of lymphedema.3 Papillomatosis—a cobblestone appearance of the skin—may also be present; it results from dilated and distended lymph vessels that are enveloped in fibrotic tissue.9 Look, too, for Kaposi-Stemmer's sign—the inability to pinch a fold of skin at the base of the second toe because the skin is so thickened—which points to a diagnosis of lymphedema.9 Make sure to note any wounds on the skin. Patients with lymphedema may have lymphorrhea, the weeping of lymph fluid, which may be copious enough to actually run or trickle down the leg. This symptom predisposes patients to cellulitis. Lymphedema can cause sensations of limb heaviness and skin tightness, heat or burning, or “pins and needles.” Some patients experience moderate to severe pain due to nerve compression from surrounding edematous tissue.10 Nerve compression may also decrease response to stimulation and predispose patients to injury and infections. Your physical assessment needs to include details on the degree of swelling, and the shape and size of the limb(s) affected; the patient's height and weight (and body mass index, if available); the functionality of the limb; and arterial competency. If the lymphedema is unilateral, quantifying the extent of swelling by comparing the size of an affected limb to a healthy one can be useful for qualifying the severity of the disease. Be aware, though, that normal anatomic variations can complicate things, and that comparison won't be possible if both limbs are affected. If the affected limb is  20% larger than the unaffected one.11 For patients with moderate to severe lymphedema, decongestive lymphedema therapy (DLT)11 is the standard treatment. Its purpose is to help mobilize lymph and dissipate fibrosclerotic tissue. In the initial treatment phase, DLT consists of manual lymph drainage (MLD), compression, scrupulous skin hygiene to prevent infection, and exercise.12-14 This is usually followed by a maintenance program consisting of compression, skin care, and exercise. If lymphedema is mild to moderate, DLT may be bypassed in favor of maintenance therapy. Note that although elevation is a core treatment for edema of venous origin, it doesn't appear to be as effective for treating lymphedema.15 However, elevation may be useful as an adjunct to the components of DLT, described below. Drug therapy and surgery are also discussed, but have limited use.16 • Manual lymph drainage is a light-pressure massage therapy designed to stimulate lymph flow by encouraging the opening and closing of the valves in lymph capillaries and vessels. The direction of massage is against gravity, from the distal to the proximal part of the limb. During the massage—a session generally lasts 30 – 60 minutes—the patient usually wears a light compression garment or stocking to maintain pressure on tissue and prevent the flow of lymph back into interstitial spaces.16 Ideally, this therapy should be administered by a certified lymphedema therapist. MLD should be avoided in patients with certain conditions, such as patients who have experienced cardiovascular failure or in whom DVT is suspected, because it will force more fluid toward the heart and may dislodge blood clots.16 MLD, however, doesn't pose a risk in patients with arterial compromise (e.g., no pulse in legs, poor circulation, diabetes, etc.). • Compression serves the dual purpose of optimizing the action of the muscles as lymph pumps and preventing further swelling. Regardless of whether patients are receiving initial treatment phase DLT or maintenance therapy, arterial competence needs to be assessed with a Doppler ultrasound prior to using compression. Before deciding to compress the affected limb, several other factors need to be considered, as well. Compression can exacerbate poor skin condition, DVT, heart conditions, inflammation, and cellulitis; it may also increase the risk of infection.16 At the same time, the lymphedema itself creates a breeding ground for infection—which is a compelling reason to use compression. Studies have demonstrated that multilayer systems reduce lymphedema more effectively than single-layer compression garments when used for the initial phase of treatment.17 Multilayered compression systems consist of three or four layers of bandaging and are used in the first two to three weeks of the initial phase of treatment.3 Multilayer bandage systems can be left on for seven days at a time before changing or are changed two to three times a week if wound care is required.18 Pneumatic compression pumps consist of a simple, multichamber sleeve that fits over the affected limb. The chambers alternately inflate and deflate according to a timed cycle, causing a peristaltic motion on the swollen tissue. Their use to control lymphedema, however, is controversial.15 Compression garments—such as stockings, sleeves, and gloves—should only be used in maintenance therapy.3 They are available off the shelf in small, medium, and large sizes, or they can be custom-made for the patient. Garments are rated to deliver 30 – 60 mm Hg of pressure.19 Patients wear the garments for most of the day and remove them at night to inspect, clean, and moisturize the skin. Check to see if your patient has an allergy to garment components, such as latex. • Fastidious skin care is a critical component of lymphedema treatment. The high protein content of lymph fluid predisposes patients to infections in the lymphedematous limb.20 A daily routine should be established in which the affected limb is inspected for wounds, cleaned, and moisturized. The routine may be altered to every two or three days, or weekly in patients who could benefit from continuous multilayer compression and whose skin is in relatively good condition. Careful inspection is especially important if there is a sensory neuropathy present. After cleansing the skin with a mild hypoallergenic soap and water, the patient should apply an emollient, preferably in the evening, for rehydration overnight. Lotions containing lanolin or fragrances should be avoided because they can cause sensitization with a resulting dermatitis. In addition, avoid petrolatum-based lotions, since they may damage compression garments. The toes and feet should also be inspected regularly for fungal infection, which is very common in patients who have lymphedema. • Exercise can help promote lymph flow and increase protein reabsorption as a result of muscle contraction.9,21 The exercise, however, should be gentle and suited to the individual's abilities and fitness level. Vigorous sports are not recommended due to the possibility of trauma.17 • Drug therapy—other than antibiotics to treat infections caused by lymphedema—has not been very useful in treating lymphedema directly. Diuretics help to purge vascular fluid, but they're ineffective in clearing out excess protein and could cause connective tissue fibrosis.22 Therefore, diuretics shouldn't be used unless there is evidence of excessive venous fluid.22 Until the lymphedema can be resolved, pain can be managed with non-opioid analgesics, relaxation techniques, mild to strong opioid analgesics, adjuvant medications—e.g., amitriptyline HCl (Elavil, Endep, others), or transcutaneous electrical nerve stimulation.1 • Surgery is reserved for grossly edematous limbs to de-bulk some of the tissue. The results have been varied, however, and conservative treatment is still required to manage the remaining lymphedema.22 Furthermore, surgical interventions on any lymphedematous limb can present severe and chronic wound healing problems. In lymphedema, two additional dimensions of nursing care should not be overlooked: patient education and psychosocial health. Patient education is critical both for the prevention and management of lymphedema—especially for cancer patients.23 Clinicians need to educate patients about the risk of developing lymphedema after surgery or radiation therapy, how to recognize lymphedema symptoms early, and how to manage the condition. You will need to advise patients, for instance, to wear loose-fitting clothing, not to cross their legs while sitting, and to avoid sitting in one position for more than 30 minutes. It's also extremely important to assess the psychosocial effects of lymphedema. The condition can cause major disfigurement and disability—an obstacle that cancer patients or survivors are often ill-equipped to overcome. Patients who experience pain from the condition report higher levels of body image disturbance and decreased sexual drive.24 The added burden of laborious, time-consuming treatments for lymphedema can further assail the patient's already fragile psyche. Psychosocial issues may be addressed by group or individual counseling, along with practical information on diet and exercise, and advice for picking comfortable and flattering clothes. Your efforts to care for patients who have—or are at risk for—lymphedema can do much good. That's true not only when it comes to patients' physical recovery, but when it comes to their psychological well-being, as well. National Cancer Institute. “Lymphedema.” Erickson, V. S., Pearson, M. L., et al. (2001). Arm edema in breast cancer patients. J Natl Cancer Inst, 93(2), 96. Burt, J., & White, G. (1999) Lymphedema. Alameda, CA: Hunter House Publishers. Thibodeau, G. A., & Patton, K. T. (2003). Anatomy and physiology (5th ed). St. Louis: Mosby. National Lymphedema Network. “Lymphedema: A brief overview.” www.lymphnet.org/whatis.html (21 Apr. 2003). Wilson, W., & Sande, M. A. (2001) Current diagnosis and treatment in infectious diseases. New York: McGraw-Hill. Board, J., & Harlow, W. (2002). Lymphedema: Classification, signs, symptoms and diagnoses. Brennan, M. J. (1992). Lymphedema following surgical treatment of breast cancer: A review of pathophysiology and treatment. J Pain Symptom Manage, 7(2), 110. Mortimer, P. S. (2000). Swollen lower limb—2: Lymphedema. The primary, secondary, and tertiary nursing interventions of lymphedema. Cancer Nurs, 8(3), 177. Exploring the use of CircAid legging in the management of lymphoedema. Int J Palliative Nurs, 6(8), 384. Casley-Smith, J. R., Casley-Smith, J. R. (1992). Modern treatment of lymphoedema. Complex physical therapy: The first 200 Australian limbs. Australas J Dermatol, 33(2), 61. Boris, M., Weindorf, S., & Lasinkski, S. (1997). Persistence of lymphedema reduction after noninvasive complex lymphedema therapy. Daane, S, Poltoratszy, P., & Rockwell, W. B. (1998). Postmastectomy lymphedema management: Evolution of the complex decongestive therapy technique. Ann Plast Surg, 40(2), 128. Brennan, M. J., & Miller, L. T. (1998). Overview of treatment options and review of the current role and use of compression garments, intermittent pumps and exercise in the management of lymphedema. Board, J., & Harlow, W. (2002). Lymphoedema 3: The available treatments for lymphoedema. Badger, C. M., Peacock, J. L., & Mortimer, P. S. (2000). A randomized, controlled parallel-group clinical trial comparing multilayer bandaging followed by hosiery vs hosiery alone in the treatment of patients with lymphedema of the limb. Kloth, L. C., & McCulloch, J. M. (Eds.). Wound healing: Alternatives in management. Philadelphia: F. A. Davis. Management of chronic edema. J Wound Care, 7(9), 3. Lymphedema: Assessment and management options. Rehab and Community Care, 12(1), 24. Cohen, S. R., Payne, D. K., & Tunkel, R. S. (2001). Lymphedema: Strategies for management. Moseley, A., & Piller, N. (2002). The assessment and care of the patient with secondary limb lymphoedema. Aust Nurs J, 10(Suppl. Passik, S. D., & MacDonald, M. V. (1998). Psychosocial aspects of upper extremity lymphedema in women treated for breast carcinoma. Newman, M. L., Brennan, M., & Passik, S. (1996). J Pain Symptom Manage, 12(6), 376. Diagnosing Lymphedema from: Step Up, Speak out Differential Diagnosis from: Lighthouse Lymphedema Network A Guide to Lymphedema: Differential Diagnosis of Lymphedema Medscape Developmental Disorders of the Lymphatics Edema and Related Medical Conditions Join us as we work for lymphedema patients everywehere: Advocates for Lymphedema Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure. http://health.groups.yahoo.com/group/AdvocatesforLymphedema/ Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com Pat O'Connor Lymphedema People / Advocates for Lymphedema Children with Lymphedema The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People. http://health.groups.yahoo.com/group/childrenwithlymphedema/ Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com …………………. Lipedema Lipodema Lipoedema No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping. Come join, be a part of the family! http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515 Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com …………………. MEN WITH LYMPHEDEMA If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema. http://health.groups.yahoo.com/group/menwithlymphedema/ Subscribe: menwithlymphedema-subscribe@yahoogroups.com …………………. All About Lymphangiectasia Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas. http://health.groups.yahoo.com/group/allaboutlymphangiectasia/ Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com …………………. Lymphatic Disorders Support Group @ Yahoo Groups While we have a number of support groups for lymphedema… there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered. DISCRIPTION Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People. http://health.groups.yahoo.com/group/lymphaticdisorders/ Subscribe: lymphaticdisorders-subscribe@yahoogroups.com …………………. Teens with Lymphedema http://health.groups.yahoo.com/group/Teens_with_Lymphedema/ …………………. All About Lymphoedema - Australia http://au.groups.yahoo.com/group/All_About_Lymphoedema/ ………………… Contact: Updated Jan. 18, 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