Difference between revisions of "Lymphatic System Assessment"

Latest revision as of 20:26, 21 September 2010

Lymphatic System

The function of this system is to:

• collect and return fluid and plasma protein to the blood which will help maintain fluid balance
• defend the body against disease by producing lymphocytes
• absorb lipids from the intestinal tract and transport them to the blood

Head/Neck Lymph Nodes

The greatest supply of lymph nodes are located in the head and neck. Sources tend to differ on the name of these lymph nodes. These particular names of the lymph nodes used correspond to adjacent structures.

• Preauricular, in front of the ear
• Posterior auricular (mastoid), superficial to the mastoid process
• Occipital, at the base of the skull
• Submental, midline, behind the tip of the mandible
• Submandibular, halfwasy between the angle and the tip of the mandible
• Jugulodigastric, under the angle of the mandible
• Superficial cervical, overlying the sternomastoid muscle
• Deep cervical, deep under the sternomastoid muscle
• Posterior cervical, in the posterior triangle along the edge of the trapezius muscle
• Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle.^[1]

Nursing Assessment

Using a gentle circular motion with your finger pads palpate each lymph node in the order previously stated. It is a good idea to palpate both sides at the same time, comparing the two sides symmetrically. Normal cervical nodes should be less than one centimeter, movable, discrete, soft, and nontender.

Abnormal Findings

If any nodes are palpable, note their location, size, shape, borders, mobility, consistency and tenderness. If any of the nodes are enlarged, greater than 1 cm, and tender it is important to give prompt attention to determine the source of the problem.

Diseases involving the Head/Neck Lymph Nodes

Lymphadenopathy, tuberculosis, HIV, Virchow's node and Hodgkin's lymphoma

Tonsils

Tonsils can be described as functioning lymph nodes located at the entrance of the respiratory and gastrointestinal tracts; the function of tonsils are to respond to local inflammation and aid the lymphatic system. The lymphatic drainage for the palatine, pharyngeal and lingual tonsils flow into the cervical lymph glands and then into the superior deep jugular nodes. The palatine tonsils are referred to as "the tonsils" and are visible in back of the mouth. The pharyngeal tonsils are located at the junction of the hard and soft palate and the lingual tonsils are located on the dorsal surface of the tongue.^[2]

Nursing Assessment

The nurse will examine the tonsils for color, presence of exudates or lesions and utilize a grading scale to describe the size and visibility of the tonsils. The nurse should grade the tonsils on a scale from +1 for visible to +4 for tonsils that are touching each other.^[3] The nurse should also palpate the mandible and neck region for swollen lymph nodes.

Abnormal Findings

If an infection is present the tonsils may appear bright red, swollen and exudates may be present. If a sore throat is present then a culture should be done to rule out strep throat.

Diseases involving the Tonsils

Tonsillitis, infectious mononucleosis, quinsy, tonsil stones and tonsil cancer [1]

Upper Limbs (Axillary) Lymph Nodes

Axillary or armpit lymph nodes drain lymph from the arms, breast, chest wall and upper abdomen Axillary lymph nodes. The breast especially has extensive lymphatic drainage. A right lymphatic duct collects lymph from the upper right quadrant of the body including the right arm and right side of the head and chest.^[4] A left lymphatatic duct collects lymph from the left side of the upper torso.

Nursing Assessment

Have the patient put on a gown for the examination. Examine the axilla of both arms while the person is sitting forward. Lift the patient's arms one at a time, and palpate the right and left axilla reaching your fingers high into the armpits. Move your hand down the chest wall from the middle of both axillae along the anterior and posterior borders, then along the inner sides of the upper arms.^[5]

Normal Findings

Normally, upper limb or axillary lymph nodes are not palpable, but you might feel a small (up to 1 cm in diameter), soft, non-tender node in the center of an armpit that is within acceptable limits.^[6]

Abnormal Findings

Observe for tenderness, lumps, or swelling in the armpit area. Note any lymph nodes that are enlarged. Large, tender but mobile nodes often indicate localized infections of the arm. Localized axillary lymphadenopathy will be bilateral. Many viral infections such as chickenpox, mononucleosis, shingles can account for this tenderness. Bacterial infections such as cat scratch disease or local skin wounds also often cause the nodes to be enlarged and tender. Inflammation and redness of the overylying skin of the armpit, breast or chest wall may be noted. Nodes from infection will gradually decrease in size upon subsequent examination.

Fixed or matted axillary lymph nodes, and skin retraction at the breast or chest wall often indicates malignancy usually from the lungs or breast. Lymph nodes harboring malignant disease tend to be firm, non-tender, matted, and fixed (not freely mobile but rather stuck down to underlying tissue) These nodules seem to be connected and move as a unit.^[7] Matted nodes can be benign such as tuberculosis, or malignant such as lymphoma. Stony-hard nodules are typically a sign of cancer, usually metastatic. These nodes will continue to increase in size with subsequent examinations.

Nursing Followup

Any patient having abnormal physical findings upon upper limb (axillary) lymph node palpation, should be referred to their primary care physician for further testing using ultrasound and CT scan. Nursing assessment by palpation is just the first step to determine a normal exam versus detecting abnormal findings of these lymph nodes.

Lower Limbs (legs)

The flow of lymph from the legs towards the heart is the result of the calf pump. As a person walks, the calf muscle contracts, squeezing lymph out of the leg via the lymphatic vessels. When the muscle relaxes, valves in the vessels shut preventing the fluid from returning to the lower extremities.^[8] The lymph from the legs is filtered through the inguinal nodes in the groin area on its way to the thoracic duct. Blockage of the inguinal nodes can contribute to swelling in the legs. From the thoracic duct, the lymph is returned to the venous circulation through the left subclavian vein.^[9]

Nursing Assessment

Assessment of the lower extremities begins with visual inspection of the legs. Color, presence of hair, visible veins, size of the legs and any sores should be noted. Lack of hair may indicate an arterial circulation problem.^[10] If swelling is observed, the calf circumference should be measured with a tape measure. This measurement can be compared to future measurements to see if the swelling is getting better. Determine if elevating the legs makes the swelling go away. Pressure should be applied with the fingertips over the ankle to determine the degree of swelling. The assessment should also include a check of the popliteal, femoral, posterior tibial, and dorsalis pedis pulses. When checking the femoral pulse, feel for the inguinal nodes and determine if they are enlarged. Enlargement of the nodes lasting more than three weeks may indicate infection or some other disease process requiring further medical attention.^[11]

Upper Torso (thymus gland)

Lower Torso (spleen)

The spleen lies in the left-upper quadrant of the abdomen. It functions to destroy old red blood cells, produce antibodies, store red blood cells and filter microorganisms from blood.

Nursing Assessment

The patient's bladder should be empty. With the patient supine, cover genitalia and female breasts. Be sure room is well lit. Patient should be comfortable with head on a pillow. Place another pillow under the patient's knees. Place patient's arms at his side. Warm hands and stethoscope prevent patient from tensing muscles during examination. Speak to the patient with a soothing voice. Unless enlarged to three times the normal size, the spleen is not usually palpable.^[12]

Abnormal Findings

Stand on the patient's right side. Place your left hand over the abdomen and behind ribs eleven and twelve. Lift upwards. Examiner's right hand should be placed obliquely on the left upper quadrant. As your fingers are pointed to the left axilla just below the rib margin, push down deeply and under the rib margin. You should feel nothing as the patient takes a deep breath. If enlarged, the spleen will move downward and slide out; you will feel it with your fingertips as it bumps you. An enlarged spleen will not normally be tender unless the peritoneum is inflamed. It is also possible to palpate the enlarged spleen with patient on right side using the same method.

Nursing Follow-up

An enlarged spleen can rupture easily. Take care not to over palpate. Enlargement could be the result of mononucleosis or trauma. The patient may report a feeling of fullness without having eaten anything. They may also present with anemia, fatigue, frequent infections and easy bleeding.

Bone Marrow

One of the largest organs in our body is bone marrow, accounting for up to 5% of our total body weight. The function of the bone marrow is to produce blood cells. This process is called hematopoiesis. Blood cell formation occurs in all skeletal bones as children, and as we age the production sites are limited to the pelvis, ribs, sternum, and vertebrae. The bone marrow itself is composed of a very vascular red marrow and a yellow fatty marrow. In the bone marrow is where the synthesis of stem cells occur.

Types of Stem Cells

• Stem cells -the original cell produced that later changes, or differentiates, into myeloid or lymphoid stem cells.
  • Myeloid cells - later become red blood cells, white blood cells, and platelets.
  • Lymphoid cells - produce T or B lymphocytes that are critical in producing and maintaining immunity.^[13]

Nursing Assessment

Nursing assessment is challenging when attempting to assess the bone marrow. A visualization of the marrow itself can only be performed by obtaining a biopsy or undergoing a bone marrow aspiration. Furthermore, defects in the production of either myeloid cells or lymphoid cells can at times be identified only at a molecular level. Nursing assessment involving bone marrow defects would be limited to maintaining comfort and providing support as well as safety.

References

^[14]

External links

• [2]
• [3]

1. ↑ Jarvis, Carolyn (2008). 5th edition. Physical Examination & Health Assessment. p. 275. ISBN 978-1-4160-3243-4.  Missing or empty |title= (help)
2. ↑ [4]
3. ↑ Jarvis, C. (2008).5th edition. Physical Examination and Health Assessment. St.Louis: Saunders Elsevier, p. 389
4. ↑ Parker, S.(2007).The Human Body Book, New York: DK Publishing p.156-157
5. ↑ Jarvis, C.,(2008) p. 410, 419
6. ↑ [5]
7. ↑ [6]
8. ↑ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). St. Louis, Missouri: Saunders Elsevier. pp. 530–553. 
9. ↑ Lua error in package.lua at line 80: module 'Module:Citation/CS1/Suggestions' not found.
10. ↑ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). St. Louis, Missouri: Saunders Elsevier. pp. 530–553. 
11. ↑ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). Philadelphia, Pennsylvania: Saunders Elsevier. pp. 530–553. 
12. ↑ Jarvis, Carolyn (2008). 5th edition. Physical Examination & Health Assessment. p. 558,559,579. ISBN 978-1-4160-3243-4.  Missing or empty |title= (help)
13. ↑ Brunner and Suddarth's Medical Surgical Nursing (2004). 10th edition. Cardiovascular, Circulatory, and hematologic function. p. 879.
14. ↑ Jarvis, C. (2008).5th edition. Physical Examination and Health Assessment. St.Louis: Saunders Elsevier, p. 410-420