Lymphatic system nursing assessment: Difference between revisions
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===Tonsils=== |
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:Tonsils can be described as functioning lymph nodes located at the entrance of the respiratory and gastrointestinal tracts. The function of the tonsils are to respond to local inflammation and aid the lymphatic systems. There are several tonsils but only three that we will focus on and they are lingual, palatine and adenoid tonsils. The palatine tonsils are more commonly refer to as the “tonsils” produce antibodies to aid the respiratory and digestive tract against infections; the palatine tonsils are visible and located on each side of the mouth. The pharyngel tonsils or adenoids are located between the hard/soft palate and can be linked to pituitary problems. The lingual tonsils are located on the upper surface of the tongue and are rarely involved in infection. As the person ages the tonsils may reach a point where they can no longer excrete toxins and the tonsils themselves create drainage into the lymph nodes of the neck, such as the superior deep jugular nodes. [http://www.patient.co.uk/showdoc/27000658] |
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====Assessment==== |
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:When assessing the tonsils the nurse will us a wooden tongue depressor to push down on the tongue, depress the tongue blade half-way back on the tongue and towards the side edge to prevent triggering the gag reflex. The nurse will examine the tonsils for color, presence of exudates or lesions. If an infection is present the tonsils may appear bright red, swollen and exudates may be present. When documenting the patient's objective data the nurse should described the tonsils appearance and then grade the tonsils on a scale that ranges from +1 to +4. With +1 showing that the tonsils are visible to +4 describing that the tonsils are touching each other. The nurse will also palpate the patient's neck feeling for enlarged lymph nodes for signs of infection or presence of disease and document locations of swollen lymph nodes. Although,tonsils may help with infections they are generally not important and can be removed.<ref>{{ cite book | author = Jarvis, C. | title = Physical Examination and Health Assessment | edition = fifth | year = 2004 | publisher = Saunders Elsevier | location = St. Louis, Missouri | page = 389 }}</ref> |
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====Diseases==== |
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:Some diseases associated with tonsils are the following:tonsillitis,infectious mononucleosis, quinsy, tonsil stones and tonsil cancer. [http://www.bbc.co.uk/dna/h2g2/A41684376] |
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===Lymph |
===Lymph Nodes of the Lower Limbs=== |
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: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 |
:Lymphatic vessels in the legs empty into the veins. The veins are able to stretch in order to accomodate increased blood and fluid in the legs. For this reason they are called ''capacitance vessels''.<ref>{{cite book | author = Jarvis,C. | title = Physical Examination and Health Assessment |edition = fifth | year = 2004 | publisher = Saunders Elsevier | location = St. Louis Missouri | pages = 530-553}}</ref> The flow of lymph and blood from the legs towards the heart is the result of the ''calf pump''. As a person walks, the calf muscle contracts, squeezing lymph and blood out of the leg. When the muscle relaxes, valves in the vessels shut preventing the fluid from returning to the lower extremities.<ref>{{ cite book | author = Jarvis, C. | title = Physical Examination and Health Assessment | edition = fifth | year = 2004 | publisher = Saunders Elsevier | location = St. Louis, Missouri | pages = 530-553 }}</ref> The lymph from the legs is filtered through the inguinal nodes in the groin area on its way to the thoracic duct.<ref>{{cite book | author = Brunner, L. | coauthor = Suddarth, D. | title = Textbook of Medical Surgical Nursing | edition = sixth | year = 1988 | publisher = JB Lippincott Company | location = Philadelphia, Pennsylvania | page = 659}}</ref> |
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====Varicose Veins==== |
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:''Varicose veins'' are veins that have lost the ability to return to normal size after stretching. They can be superficial or deep. Superficial varicose veins are usually visible upon inspectionof the legs. Deep varicose veins occur when there is or has beeb an obstruction in the vessels. The valves in these vessels may also not work properly allowing back flow of fluid. This results in venous stasis or pooling of blood and fluids in the lower extremities. Varicose veins can cause muscle cramping, muscle fatigue, and muscle aches. They can also contribute to swelling resulting in lymphedema.<ref>{{ cite book | author = Brunner, L. | coauthor = Suddarth, D. | title = Textbook of Medical Surgical Nursing | edition = sixth | year = 1988 | publisher = JB Lippincott Company | location = Philadelphia, Pennsylvania | page = 658}}</ref> Lymphedema or swelling can become a chronic, disfiguring illness. [[Lymphedema]] |
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====Assessment==== |
====Assessment==== |
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: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. |
:Assessment of the lower extremities begins with visual inspection of the legs. Color, presence or absence of hair, visible veins, size of the legs and any sores should be noted.<ref>{{ cite book | author = Jarvis, C. | title = Physical Examination and Health Assessment | edition = fifth | year = 2004 | publisher = Saunders Elsevier | location = St. Louis, Missouri | pages = 530-553}}</ref> 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. [[Lymphedema]] 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. <ref>{{ cite book | author = Jarvis, C. | title = Physical Examination and Health Assessment | edition = fifth | year = 2004 | publisher = Saunders Elsevier | location = Philadelphia, Pennsylvania | pages = 530-553}}</ref> Treatment of swelling of the legs depends on the cause. For chronic conditions, compression of the legs by either elastic stockings, mechanical pumps, or massage is common. [[Lymphedema]] |
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== References == |
== References == |
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Revision as of 20:57, 13 November 2009
Lymph Nodes of the Lower Limbs
- Lymphatic vessels in the legs empty into the veins. The veins are able to stretch in order to accomodate increased blood and fluid in the legs. For this reason they are called capacitance vessels.[1] The flow of lymph and blood from the legs towards the heart is the result of the calf pump. As a person walks, the calf muscle contracts, squeezing lymph and blood out of the leg. When the muscle relaxes, valves in the vessels shut preventing the fluid from returning to the lower extremities.[2] The lymph from the legs is filtered through the inguinal nodes in the groin area on its way to the thoracic duct.[3]
Varicose Veins
- Varicose veins are veins that have lost the ability to return to normal size after stretching. They can be superficial or deep. Superficial varicose veins are usually visible upon inspectionof the legs. Deep varicose veins occur when there is or has beeb an obstruction in the vessels. The valves in these vessels may also not work properly allowing back flow of fluid. This results in venous stasis or pooling of blood and fluids in the lower extremities. Varicose veins can cause muscle cramping, muscle fatigue, and muscle aches. They can also contribute to swelling resulting in lymphedema.[4] Lymphedema or swelling can become a chronic, disfiguring illness. Lymphedema
Assessment
- Assessment of the lower extremities begins with visual inspection of the legs. Color, presence or absence of hair, visible veins, size of the legs and any sores should be noted.[5] 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. Lymphedema 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. [6] Treatment of swelling of the legs depends on the cause. For chronic conditions, compression of the legs by either elastic stockings, mechanical pumps, or massage is common. Lymphedema
References
- ^ Jarvis,C. (2004). Physical Examination and Health Assessment (fifth ed.). St. Louis Missouri: Saunders Elsevier. pp. 530–553.
- ^ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). St. Louis, Missouri: Saunders Elsevier. pp. 530–553.
- ^ Brunner, L. (1988). Textbook of Medical Surgical Nursing (sixth ed.). Philadelphia, Pennsylvania: JB Lippincott Company. p. 659.
{{cite book}}: Unknown parameter|coauthor=ignored (|author=suggested) (help) - ^ Brunner, L. (1988). Textbook of Medical Surgical Nursing (sixth ed.). Philadelphia, Pennsylvania: JB Lippincott Company. p. 658.
{{cite book}}: Unknown parameter|coauthor=ignored (|author=suggested) (help) - ^ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). St. Louis, Missouri: Saunders Elsevier. pp. 530–553.
- ^ Jarvis, C. (2004). Physical Examination and Health Assessment (fifth ed.). Philadelphia, Pennsylvania: Saunders Elsevier. pp. 530–553.