Copyright 2017 Wolters Kluwer Health, Inc. All Rights Reserved.

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Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

1.5ANCCCONTACT HOURSLooking intosecondarylymphedemaS OMKIATFAKMEE / iSTOCKBy Kaitlyn Gregory, DNP, RN, FNP-BC, and Linda Schiech, MSN, RNLYMPHEDEMA is a congenital (primary) or mechanical (secondary)abnormality in the lymphatic systemthat results in an abnormal accumulation of interstitial fluid and fibroustissue in a specific area in a person’sbody.1 This article focuses on secondary lymphedema, usually causedby lymph node dissection or lymphadenectomy for cancer staging inconjunction with tumor removal.Recent advances in microvascularsurgery are discussed. Primarylymphedema, generally due tocongenital or inherited disorders, isbeyond the scope of this article.This article also emphasizes patient teaching. Nurses can help post-www.Nursing2017.comsurgical patients learn how toprevent lymphedema and recognizethe early signs and symptoms oflymphedema or infection. Lymphedema can’t be cured once diagnosed and can be challenging totreat in its later stages.1 Early treatment for lymphedema can minimizecomplications such as fibrosis,hyperpigmentation, and fissures.Teaching patients how to prevent ormanage lymphedema improves theirself-esteem and quality of life.2-4PathophysiologyThe edema associated with lymphedema differs from the generalizededema resulting from chronicvenous insufficiency or fluid overload. Although both general edemaand lymphedema cause edema inthe extremity, lymphedema iscaused by protein-rich lymph fluidand general edema is caused bytissue-related fluid.5,6 Lymphedemacan occur when the lymphatic loadexceeds the lymph system’s transport capacity, which causes filteredfluid to build up in the interstitium.Secondary lymphedema results froma disorder or treatment, such as cancer or treatment for cancer such asaxillary node dissection, infection,inflammatory disease, obesity, trauma, burns, and chronic venousinsufficiency.1,6November l Nursing2017 l 35Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

The most common cause of secondary lymphedema is surgical intervention for a malignancy whenlymph node dissection is performed.1,6 Radiation therapy for cancer is another common cause.Most common sites forlymphedemaMost cancer surgeries require lymphnode removal or, at the least, lymphnode sampling, also called lymphnode biopsy. In larger areas such asthe abdomen and the chest, otherparts of the lymphatic system suchas the thoracic or lymphatic ductcan help with collateral drainage,and generally more room for edemais found in the abdomen.7 The areasof the body that most commonlydemonstrate lymphedema are theupper extremities, related to the axillary lymph nodes; the lower extremities, related to the inguinal lymphnodes; and the neck, related to cervical and supraclavicular lymphNormal anatomy and physiology of thelymphatic systemThe lymphatic system is an extensivevascular network that drains lymph fluidfrom body tissues and returns it to thevenous circulation. The system startsperipherally as blind lymphatic capillaries, continues centrally as thin vascularchannels, then as collecting ducts, andempties into the major veins at the neck.Lymph fluid transported through thesechannels is filtered through lymph nodesinterposed along the way.Lymph nodes are round, oval, orbean-shaped structures that vary in sizeaccording to their location. Some lymphnodes, such as the preauricular nodes, ifpalpable at all, are typically very small.The inguinal nodes, by contrast, are relatively larger—often 1 cm in diameter andoccasionally even 2 cm in an adult.In addition to its vascular functions,the lymphatic system plays an important role in the body’s immune system.Cells within the lymph nodes engulf cellular debris and bacteria and produceantibodies.Only the superficial lymph nodes are accessible to physical assessment. Theseinclude the cervical nodes, the axillary nodes, and nodes in the arms and legs.Recall that the axillary lymph nodes drain most of the arm. Lymphatics fromthe ulnar surface of the forearm and hand, the little and ring fingers, and theadjacent surface of the middle finger, however, drain first into the epitrochlearnodes. These are located on the medial surface of the arm approximately 3 cmabove the elbow. Lymphatics from the rest of the arm drain mostly into theaxillary nodes. A few may go directly to the infraclavicular nodes. The lymphaticsof the lower limb, following the venous supply, consist of both deep and superficial systems.The superficial inguinal nodes include two groups. The horizontal group lies in achain high in the anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the external genitalia (but not thetestes), the anal canal and perianal area, and the lower vagina.Source: Bickley LS. Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: WoltersKluwer Health/Lippincott Williams & Wilkins; 2013.nodes.1,6 (See Normal anatomy andphysiology of the lymphatic system.)IncidenceLymphedema is seen more frequentlyin females than males.1 The incidence of upper extremity lymphedema for breast cancer survivors is17%, with the greatest incidencewithin the first 2 years after breastcancer diagnosis. The National Cancer Institute reports that womenwho’ve undergone treatment forbreast cancer may experiencelymphedema within days of treatment or up to 30 years posttreatment.8 (See Lymphatic drainage of thebreast.)Lower extremity lymphedemaoccurs most often in patientswho’ve undergone treatment foruterine or prostate cancer, lymphoma, or melanoma.6Risk factorsThe main risk factor for secondarylymphedema is a lymph node dissection as part of surgical cancer treatment,most commonly after a modifiedradical mastectomy or a lumpectomy.6,8 Because clinicians have beenusing more breast-conserving techniques in the past decade, many patients are having a lumpectomy anda sentinel lymph node biopsy of justthe first few nodes that drain thetumor being removed. Statisticsshow that these patients can stilldevelop lymphedema, but at alower frequency—5% for sentinellymph node dissection versus 19%for axillary lymph node dissection.Patients having less radical surgeriesmust still follow lymphedema precautions.9A surgical resection of an upperbody melanoma sometimes requiresan axillary node dissection. Lowerextremity lymphedema can be causedby inguinal lymph node dissectionsafter a resection for a melanoma ofthe lower extremity or extensivegynecologic procedures.6,8,10,1136 l Nursing2017 l Volume 47, Number 11Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2017.com

Lymph node dissections are oftenperformed during head and necksurgeries. Neck lymphedema can bevery discouraging, especially after analready-disfiguring procedure.12 (SeeHead and neck lymph nodes.)Other risk factors for lymphedema include tumor compression ofthe lymphatic system in the axilla,the neck, the groin, the abdomen, orthe chest. The risk of lymphedema isincreased when the patient has largetumors, which may compress thelymphatic system, and in later stagesof disease, when the patient has positive lymph nodes because largertumors tend to be associated withmore positive lymph nodes.1,8,13External beam radiation can causefibrosis and muscle wasting, leavingthe lymphatic system functioningimproperly. Obesity is another riskfactor because parts of the lymphaticsystem can be blocked by excessiveadipose tissue.Cellulitis is a localized skin infection that can lead to lymphedema,and long-standing repeated exacerbations of lymphedema can lead torecurrent incidents of cellulitis.14Signs and symptomsClinical manifestations of lymphedema related to axillary nodedissection include complaints ofjewelry or clothing being too tight;a thick, heavy, or full feeling inthe affected arm; pain; edema;decreased flexibility in the elbowor shoulder area; and feeling thatit’s an effort to lift things or writeusing the affected limb.1,3,8Lymphatic drainage of the breastLymphatics of mostof the breast drainSupraclaviculartoward the axilla.LateralInfraclavicularOf the axillarylymph nodes, theCentral(deep within axilla)central nodes aremost likely to beSubscapular(posterior)palpable. They liePectoralalong the chest(anterior)wall, usually high inthe axilla and midway between theanterior and posterior axillary folds.Into them drain channels from three other groups of lymph nodes, which are seldom palpable: Pectoral nodes—anterior, located along the lower border of the pectoralis majorinside the anterior axillary fold. These nodes drain the anterior chest wall andmuch of the breast. Subscapular nodes—posterior, located along the lateral border of the scapula;palpated deep in the posterior axillary fold. They drain the posterior chest walland a portion of the arm. Lateral nodes—located along the upper humerus. They drain most of the arm.Lymph drains from the central axillary nodes to the infraclavicular and supraclavicular nodes.Not all the lymphatics of the breast drain into the axilla. Malignant cells from abreast cancer may spread directly to the infraclavicular nodes or into the internalmammary chain of lymph nodes within the chestSource: Bickley LS. Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: WoltersKluwer Health/Lippincott Williams & Wilkins; 2013.At first, peripheral lymphedemamay present as pitting edema orcellulitis. (See Picturing lymphedema.)It could be related to an injury oran infection. Lymphedema caninvolve patients’ fingers, makingit very hard to put on rings or evenform a fist.3If not diagnosed and treatedproperly, lymphedema evolves intononpitting edema and fibrosis. ThePicturing lymphedemaNo pittingThick skinEdematous footLymphedema is soft in the early stages,then becomes indurated and nonpitting.Skin is markedly thickened; ulcerationis rare.Source: Bickley LS. Bates’ Guide to Physical Examinationand History Taking. 11th ed. Philadelphia, PA: WoltersKluwer Health/Lippincott Williams & Wilkins; 2013.www.Nursing2017.compatient feels that the arm is heavier,and it’s firm to palpation.1,5The skin of an area with lymphedema that’s hyperpigmented andthickened is very fibrotic. If thelymphedema is left untreated, theinvolved area can be at high risk forbreakdown and fissures.1With lower extremity lymphedema, patients may say that theirclothes, the elastic on their underwear, or shoes feel too tight. Somepatients have difficulty ambulating.15AssessmentBecause the onset of lymphedemais subtle, clinicians should performongoing assessments of high-riskpatients at every clinical evaluation.This includes comparing the involved extremity with the contralateral extremity. Measuring limbNovember l Nursing2017 l 37Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

circumference and tracking thosemeasurements is a general methodused by clinicians that’s also taughtto patients.When comparing two extremities,the same areas should be measuredevery time. The joints of the fingersand toes should be measured ifthey’re edematous. The wrist and/orthe ankle should be measured aswell as 10 cm above and below theelbow and/or 10 cm above or belowthe patella. Many patients are followed by physical therapists (PTs) oroccupational therapists (OTs) at afacility for these ongoing measurements.1 (See Staging lymphedema.)DiagnosisEarly diagnosis is critical so thattreatment will be as effective as possible. Clinicians should monitorhigh-risk patients by obtaining anaccurate health history and performing a comprehensive physical assess-Staging lymphedemaLymphedema can be categorized by using the National Cancer Institute CommonTerminology Criteria for Adverse Events. The stage is based on assessment findingsand the degree of functional impairment, which are generally the clinical stageslisted here. Grade 1–Trace thickening or faint discoloration Grade 2–Marked discoloration, leathery skin texture, papillary formation, limitinginstrumental activities of daily living Grade 3–Severe signs and symptoms limiting self-care and activities of daily living.Source: Mohler ER III, Mehrara B. Clinical staging and conservative management of peripheral lymphedema.Up To Date; 2017. www.uptodate.com.ment including circumference measurements of the affected limb andthe contralateral limb.1Lymphedema is often diagnosedusing radiologic imaging.6 Lymphedema may not be noticeable, and itcan even be microscopic.2,10Ultrasound can assist in differentiating lymphedema from othervascular disorders. Computerizedtomography or magnetic resonanceimaging can help to determine ifHead and neck lymph nodesThe lymph nodes ofthe head and neck areclassified in a varietyPreauricularof ways. One classification is shown here,together with thePosteriorauriculardirection of lymphaticTonsillardrainage. The deepOccipitalcervical chain is largely obscured by theSuperficialSubmentaloverlying sternomascervicaltoid muscle, but at itsPosterior cervicalSubmandibulartwo extremes, theSupraclavicularDeep cervical chaintonsillar node andsupraclavicular nodes,may be palpable. Thesubmandibular nodeslie superficial to thesubmandibular gland,External lymphatic drainageInternal lymphatic drainageand should be differ(from mouth and throat)entiated. Nodes arenormally round orovoid, smooth, and smaller than this gland. The gland is larger and has a lobulated,slightly irregular surface. Note that the tonsillar, submandibular, and submentalnodes drain portions of the mouth and throat as well as the face.Source: Bickley LS. Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: WoltersKluwer Health/Lippincott Williams & Wilkins; 2013.fluid is in the peripheral soft tissues.1 Lymphoscintigraphy imagesthe flow of fluid from the skin tothe lymph nodes, especially in theextremities.Bioimpedance analysis usesresistance to electrical current incomparing the composition of bodyfluid compartments to help detectlymphedema.6A newer method of diagnosisinvolves an off-label use of indocyanine green (ICG) for lymphangiography. ICG is injected between thefingers, and infrared light near theskin demonstrates the lymph flow.Patients with lymphedema don’t havegood linear flow or have a dim-lookingflow.16 This exciting new testing isdynamic, allowing lymphedema to bediagnosed in real time.1Noninvasive therapiesPatients with peripheral lymphedema should avoid using an affectedlimb to lift or carry heavy objects.Patients with lower extremitylymphedema shouldn’t cross theirlegs for extended periods. Becausesigns and symptoms are more common in those with an increasedbody mass index, weight management is important.6Compression, the main conservative treatment for lymphedema, canbe obtained with compression garments or compression bandagesthat wrap around the extremity.Intermittent pneumatic compression is used to achieve an optimal38 l Nursing2017 l Volume 47, Number 11Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2017.com

amount of pressure. One benefit isthat patients can be taught to usethis therapy themselves at home.2Although compression is usuallyprovided by PTs or OTs who’vebeen specially educated in lymphedema management, nurses can alsobe educated.2,17Sleeve and leg garments can havelayers of compression material. Patients are measured and garmentsare sized for their original limb sizeplus the amount of lymphedema.Smaller garments may be used as thelymphedema is reduced. Althoughcompression garments and bandagesmay feel tight and constricting atfirst, they’re the first line of treatment for this disorder.6,17-19During the first level of compression therapy, patients are fitted withlayers of bandaging or garments; thegreatest amount of pressure thatpatients can tolerate is best for decreasing the edema. In the secondlevel of therapy, patients use garments fitted to their present ormaintenance level of edema to maintain that level during regular highrisk activities such as a plane flightor rides in amusement parks thatput the limb under a high degree ofpressure and can exacerbate lymphedema.2,5,20 In general, edema can bereduced by approximately 31% withcompression bandages and 46%with garments.5Daily moisturizing is imperativeunder garments or bandages andwhen the patient has edema. Usingmoisturizers, preferably water-based,maintains the skin’s integrity, prevents fissures, and avoids infection.3,5Some patients may have to useadditional dressings to collect drainage or protect the skin. Once thelymphedema lessens, patients maywear the garments occasionally tokeep the lymphedema under controlor to participate in high-risk activities as mentioned above.2,20Another method of treatinglymphedema is manual lymphaticwww.Nursing2017.comments. As with MLD, patients aretaught to continue to use their compression garments and practice optimal skin care at home.2No pharmacologic agent hasshown any positive results in treating lymphedema although researchon anti-inflammatory and antifibrotic agents continues.21,22Lymphedema can’tbe cured oncediagnosed and can bechallenging to treat inits later stages.drainage (MLD) therapy, which isalso often performed by speciallytrained PTs or OTs, nurses, and massage therapists. MLD uses mostlymassage and light pressure to assistin the manual drainage of lymphatics. The fluid is moved from thedistal or most peripheral area proximally into other areas where thelymphatics are functioning properly.The patient’s compression garmentsshould be placed after MLD for themost effective treatment.2 Togetherthe two techniques have producedas much as a 60% decrease inedema.5,17Complete decongestive therapy issimilar to MLD with very thoroughmanual lymphatic drainage and theuse of compression bandages andgarments to follow. Excellent skincare is stressed for the prevention ofinfection and irritation from the gar-Surgical optionsIndications for surgery include exhaustion of conservative measuressuch as compression and completedecongestive therapy. Candidates forsurgical management include patientswith recurrent cellulitis, pain, disfigurement, and localized primary lesions.23 Surgical management involvesphysiologic or reductive techniques.Physiologic techniques reroutelymphatic drainage by creating newconduits for the fluid so that it canempty into different lymphaticdrainage areas or the venous circulation.23 Lymphovenous bypass procedures, performed by a surgeontrained in microvascular surgery, isthe most commonly used physiologic approach to surgical managementof lymphedema. The approachto bypass surgery can be eitherlymphatic-lymphatic, lymphovenous, or lymphaticovenular.23 Lymphatic-lymphatic bypass transfers healthy lymph tissue that’s microsurgically anastomosed to theaffected tissue.23 The lymphovenous bypass uses avein graft to connect distal lymphvessels with vessels proximal to theobstruction.23 Lymphaticovenular anastomosisconnects distal subdermal lymphatic vessels to adjacent venules; thepressure in the subdermal venulesis lower than in deeper veins, creating less venous backflow to helpimprove lymphedema.23Reductive techniques removethe fibro-fatty tissue generated byprolonged lymphatic fluid poolingand are considered palliative, notNovember l Nursing2017 l 39Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

curative, for secondary lymphedema. The goal is to alleviate signsand symptoms.23 Reductive surgeryincludes direct excision and liposuction.Direct excision is most often usedfor genital and extremity lymphedema, with excised areas often covered with a skin graft or tissue flap,which functions more effectively forpatients who will retain excessiveskin following the procedure or following liposuction. Liposuction withspecialized suction cannulas, whichcan be used to remove some of thesubcutaneous fatty tissue, may improve the cosmetic appearance ofthe limb.5Postoperative care andcomplicationsFollowing lymphovenous bypassprocedures, keep the affected limbelevated during patients’ entire hospital stay. Frequently monitor circulation, sensation, and movement ofthe affected limb. Elastic supportbandages will be in place for thefirst 24 to 48 hours postoperatively.Garments aren’t usually used on thelimb immediately postoperativelybecause of the risk of skin shearing;however, once the surgical site isstabilized, compression garmentsare used until clinicians and patients determine that the surgerywas successful enough to discontinue their use.23,24After a direct excision procedure,most patients have a drain in place.Teach patients drain care, includinghow to empty the drain and recordthe amount and characteristics ofdrainage; perform dressing changes;and care for the skin around thedrain. Many patients have long hospital stays and poor wound healingafter the direct excision of skin andfat.23 Teach patients the signs andsymptoms of infection and tell themto notify their healthcare providerimmediately in case of any problems, such as fever or purulentEarly treatment forlymphedema canminimize complicationssuch as fibrosis andfissures.drainage from the incision site ordrain.After liposuction procedures, patients are at high risk for bleedingdue to the large volume of fat andadipose tissue that’s been removed,but the use of tourniquets andepinephrine during the procedurereduces the risk.23 Monitor thepatient for signs and symptoms ofbleeding postoperatively. Compression garments will help to preventbleeding. The assistance of thelymphedema specialist (usually thePT or OT) will most likely be required because the garments willprobably need to be resized. Patients will need to continue to wearcompression garments or bandagesfor the long term.Postoperative management includes using compression garmentsimmediately after the liposuctionprocedure and up to 12 months afterward. Prophylactic antibioticsmay be prescribed for up to 1 yearafter surgery and excellent skin care,including moisturizing, will beneeded because of the high risk ofinfection.23Cellulitis is a common issue forpatients with lymphedema. Patternsof recurrent and increasingly worsecellulitis can occur in 23% to 35%of patients with lymphedema.3,16Teach patients the vital importanceof skin hygiene and how to monitor for early signs and symptoms ofinfection.Lymphangiosarcoma is a rare butserious complication of chroniclymphedema. Seen most often inpatients who’ve had a mastectomy,this secondary malignancy most often affects patients with massive andprotracted lymphedema.25Patient education andquality of lifeThe overall goals for patients vulnerable to lymphedema are preventionand early detection and treatment.26Patient education is crucial in achieving these goals. Patients need to understand how to avoid engaging inhigh-risk behaviors and advocate forthemselves by warning healthcareworkers to avoid risky practiceswhenever possible. These include BPmeasurements and venipunctures inthe affected limb. Patients shouldalso be taught to recognize the signsand symptoms of lymphedema andto seek care from their oncologistpromptly if they appear.Lifestyle modifications and selfcare are essential to prevent lymphedema or manage symptoms. A2016 study found that 85% ofpatients with head and neck lymphedema practiced self-care activities.27Patients in this study reported onthe importance of in-person interaction, lymphedema education beforetreatment, follow-up evaluation,and visualization of self-care. Teach40 l Nursing2017 l Volume 47, Number 11Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.www.Nursing2017.com

patients with lymphedema or at riskfor it that they’ll need to continuethese self-care measures for theirentire lifetime.To optimize their health and meettreatment goals, patients shouldstrive to balance physical activitywith rest. Encourage patients to beactive, as tolerated, and to avoid asedentary lifestyle.An infection in a person withlymphedema or at risk for it can potentiate or worsen the lymphedema.Teach patients about proper precautions, as discussed below, such asgood skin care and hygiene to helpprevent infection. Meticulous skincare is vital in the postoperativeperiod; skin should be well moisturized and cleaned daily. Patientsshould use gentle, nonalcoholic,water-based creams or emollientsto prevent cracked or dry skin. Encourage patients with lymphedemato use an electric razor; avoid insectbites; cut nails straight across or seea podiatrist for nail care; avoid cuticle cutting; and be aware of theearly signs and symptoms of infection such as new onset of edema,erythema, or warmth.3-5,14Patients should avoid anythingthat applies pressure to the affectedlimb, including tourniquets used forvenipuncture. Everyday precautionsinclude avoiding constricting jewelry, such as tight bracelets or watches, and gloves. Patients with lowerextremity lymphedema should avoidclothing such as socks and pantswith elastic bands. Women with upper extremity lymphedema shouldwear a loose-fitting bra to avoidpressure to the axillary region.1,3,4Air travel can trigger or worsenlymphedema. For example, lower airpressure during flights may allowpooling in the lymphatic system.2,14Wearing a compression garmentduring the flight may help offset thisrisk. However, a recent study suggests that air travel for patients withupper extremity lymphedema isn’twww.Nursing2017.comcompleted disease treatment and arefeeling better about themselves,lymphedema can occur, affectingtheir quality of life.28,29Wrapping upFor patients who develop lymphedema, the primary goal is early diagnosis and treatment to get themback to baseline as soon as possible.Patient education is essential to helpthem resume their usual activitiesand improve their overall quality oflife. Nurses’ knowledge and care canmake a difference in these patients’lives. REFERENCES1. Mohler ER III, Mehrara B. Clinical features anddiagnosis of peripheral lymphedema. www.uptodate.com. 2017.2. Mehrara B. Breast cancer-associated lymphedema.www.uptodate.com. 2017.Patients withlymphedema or at risk ofit should continue selfcare measures for therest of their lives.associated with increased extremityvolume.20 Sitting still for prolongedperiods is another risk; patientsshould be sure to walk and stretchfrequently during their flight. Deepabdominal breathing may also helpfacilitate lymph flow. Lifting and carrying luggage can also trigger orworsen lymphedema; patientsshould seek assistance with theirluggage.Patients should monitor for signsand symptoms of lymphedema, including limb heaviness, weakness,or aching; skin tightness, pain, ornumbness; and an impaired range ofmotion. Any of these warrantsprompt evaluation by a healthcareprovider.Most of the quality of life researchon lymphedema has studied breastcancer survivors, but even that research is limited. Lymphedema is achronic disease. After patients have3. Fu MR. Breast cancer-related lymphedema:symptoms, diagnosis, risk reduction, and management. World J Clin Oncol. 2014;5(3):241-247.4. Fu MR, Axelrod D, Guth AA, et al. Proactiveapproach to lymphedema risk reduction: aprospective study. Ann Surg Oncol. 2014;21(11):3481-3489.5. Maclellan RA, Greene AK. Lymphedema. SeminPediatr Surg. 2014;23(4):191-197.6. Shaitelman SF, Cromwell KD, Rasmussen JC, etal. Recent progress in the treatment and preventionof cancer-related lymphedema. CA Cancer J Clin.2015;65(1):55-81.7. Bruera E, Higgenson I, von Guten CF, Morita T.Textbook of Palliative Medicine. Boca Raton, FL: CRCPress; 2009.8. National Cancer Institute. Lymphedema (PDQ)Health Professional Version. 2015. -effects/lymphedema/lymphedema-hp-pdq.9. Bhatt NR, Boland MR, McGovern R, et al. Upperlimb lymphedema in breast cancer patients in theera of Z0011, sentinel lymph node biopsy and breastconservation. Ir J Med Sci. [e-pub Jul. 27, 2017.]10. Yost KJ, Cheville AL, Al-Hilli MM, et al.Lymphedema after surgery for endometrial cancer:prevalence, risk factors, and quality of life. ObstetGynecol. 2014;124(2 Pt 1):307-315.11. Beesley VL, Rowlands IJ, Hayes SC, etal. Incidence, risk factors and estimates of awoman’s risk of developing secondary lower limblymphedema and lymphedema-specific supportivecare needs in women treated for endometrialcancer. Gynecol Oncol. 2015;136(1):87-93.12. Deng J, Ridner SH, Dietrich MS, et al.Prevalence of secondary lymphedema in patientswith head and neck cancer. J Pain Symptom Manage.2012;43(2):244-252.13. Vieira RA, da Costa AM, de Souza JL, et al. Riskfactors for arm lymphedema in a cohort of breastcancer patients followed up for 10 years. Breast Care(Basel). 2016;11(1):45-50.November l Nursing2017 l 41Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved.

14. Asdourian MS, Skolny MN, Brunelle C, SewardCE, Salama L, Taghian AG. Precautions for breastcancer-related lymphoedema: risk from air travel,ipsilateral arm blood pressure measurements, skinpuncture, extreme temperatures, and cellulitis.Lancet Oncol. 2016;17(9):e392-e405.15. Morris C, Wonders KY. Concise review on thesafety of exercise on symptoms of lymphedema.World J Clin Oncol. 2015;6(4):43-44.16. Mihara M, Hara H, Araki J, et al. Indocyaninegreen (ICG) lymphography is superior tolymphoscintigraphy for diagnostic imaging ofearly lymphedema of the upper limbs. PLoS ONE.2012;7(6):e38182.17. Murdaca G, Cagnati P, Gulli R, et al. Currentviews on diagnostic approach and treatment oflymphedema. Am J Med. 2012;125(2):134-140.18. Mohler ER III, Mehrara B. Clinical stagingand conservative management of peripherallymphedema. 2017. www.uptodate.com.19. O’Toole J, Jammallo LS, Skolny MN, et al.Lymphedema following treatment for breastcancer: a new approach to an old problem. Crit RevOncol Hematol. 2013;88(2):437-446.20. Ferguson CM, Swaroop MN, Horick N, et al.Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on therisk of lymphedema for patients

11th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013. No pitting Thick skin Edematous foot Lymphatic drainage of the breast Lymphatics of most of the breast drain toward the axilla. Of the axillary lymph nodes, the central nodes are most likely to be palpable. They lie along the chest wall, usually high in