10.3 Subjective Assessment
Subjective assessment of the lymphatic system involves asking questions about the health of the client and symptoms that occur because of pathologies affecting this system. Subjective assessment related to the lymphatic system is typically conducted as part of assessments related to peripheral vascular, gastrointestinal, respiratory, genital, and musculoskeletal systems.
A full exploration of pathologies is beyond the scope of this chapter, but common problems associated with the lymphatic system include lymphadenopathy, lymphedema, and cancers of the lymphatic system such as lymphomas.
Common symptoms that can be related to the lymphatic system include noticeable lymph nodes, skin changes (swelling; tight, hard skin; leaking fluid), headache, general fatigue, and fever. See Table 10.1 for guidance on subjective health assessment. Many of the questions in the table align with the PQRSTU mnemonic; you should probe symptoms in the order of relevance, rather than sequentially according to the mnemonic. For a reminder, check out this resource: PQRSTU.
You should also ask about any medications (prescribed or over the counter) the client is taking: name, dose, frequency, reason it was prescribed, how long they have been taking it, and effectiveness. Always ask about herbal and natural products.
Also ask questions related to health promotion. Depending on the context of the assessment, you may ask these questions and engage in a discussion during a subjective assessment or after an objective assessment. A section on “Health Promotion Considerations and Interventions” is included later in this chapter, after the discussion of objective assessment.
Knowledge Bites
Many lymphatic system pathologies result in swelling. For example, clients may report or you may observe lymph node swelling (a raised lump under the skin). Lymph node swelling is often the body’s way of filtering pathogens possibly related to an upper respiratory infection, flu, or cold; swelling is typically localized (in one area) and usually resolves within 1–2 weeks after the condition resolves. In these cases, lymph nodes are often tender, enlarged, and warm to touch with some localized redness. Abnormal characteristics are discussed below under priorities of care.
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Symptoms |
Questions |
Clinical tips |
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Noticeable lymph nodes associated with the lymphatic system can be described as lumps, swollen, palpable, and/or painful. |
Have you noticed any lymph nodes (or lumps) on your head, neck, under your arms, or in your groin area? If the client’s response is affirmative, additional probes may include: Region: Where do you feel the nodes? Quality/quantity: Tell me about it. What does it feel like (e.g., hard, soft)? Is there pain associated with it? (You might need to use the word “tender.”) If so, how bad is the pain/tenderness? Severity: If there is pain, can you rate your pain on a scale of 0–10 with 0 being no pain and 10 being the worst pain you have ever had? Timing: When did you notice the lymph nodes (or pain/tenderness)? Were you sick when you noticed them? Are the nodes constantly swollen? Provocative/palliative: Does anything make it worse? Does anything make it better? Treatment: Have you treated it with anything? Do you take any medications for it? Understanding: Do you know what is causing it or what it is related to? |
Many clients refer to lumps without being aware that they are lymph nodes. Therefore, you may need to use this terminology in your assessment. Use a calm demeanor with clients and help them understand that most lymph node issues are not concerning or malignant. Swollen lymph nodes are often a sign that one’s lymphatic system is working effectively and indicating that the body is filtering pathogens when a person is sick. In addition to asking the client about the nodes, inquire about any associated symptoms (e.g., pain, fatigue, unexplained weight loss, persistent fever, fainting, breathing issues) and palpate the nodes. Depending on the location of the nodes, you may also ask about symptoms related to respiratory infections (e.g., runny nose, sore throat, cough). |
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Skin changes can occur with lymphadenopathy and lymphedema. With lymphadenopathy, skin changes may include swelling, redness, and warmth over the affected lymph nodes. With lymphedema, localized skin changes may include swelling, a feeling of fullness/heaviness, redness, tight and firm skin, dry and thick skin, and leaking fluid and blisters when severe. |
Have you noticed any changes in your skin? (You might ask about specific changes like those in the column to the left). If the client’s response is affirmative, additional probes may include: Quality/quantity: Tell me about the changes. What does it feel like? What does it look like? How bad is it? Region: Where are these changes? Have you noticed them anywhere else? Timing: When did you notice these changes? Are they constant or intermittent? Provocative/palliative: Does anything make it worse? Does anything make it better? Treatment: Have you treated it with anything? Do you take any medications for it? Understanding: Do you know what is causing it or what it is related to? |
Skin changes associated with lymphedema are often associated with chronic conditions and can be significant enough to affect body image. Lymphedema can be caused by various conditions and treatments (e.g., cancer surgery, radiation) that disrupt the flow of lymphatic fluids returning to the blood. It often affects arms and legs, and can also affect the breasts, chest, abdomen, face, and neck depending on the cause. One of the first symptoms that clients experience is the feeling that the clothing or jewelry (e.g., rings and bracelets) that they are wearing seem to fit tighter. |
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Other lymphatic system symptoms may include fatigue, unexplained weight loss, weight gain, persistent fever, headache, dizziness, fainting, difficulty moving a limb or area of the body, breathing issues, coughing, and night sweats. An individual may experience a host of other associated symptoms depending on the lymphatic condition. |
It is important to ask about other symptoms, particularly if the client answers in the affirmative about noticeable lymph node changes or skin changes, or if you suspect a lymphatic condition. Use variations of the PQRSTU mnemonic to assess these associated symptoms further. |
Explore these symptoms specifically if the client answers affirmatively, but also recognize that these symptoms can be related to many other body systems. Affirmative answers related to fever, anorexia, chills, and fatigue can help you determine if the cause is systemic. |
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Personal and family history of lymphatic conditions and diseases. As noted above, common issues associated with the lymphatic system include lymphadenopathy, lymphedema, lymphatic-related cancers, cancer treatments, or physical traumas. |
Do you have any chronic conditions or diseases that affect your lymphatic system? Do you have any family members with conditions or diseases that affect the lymphatic system? If the client responds in the affirmative, begin with an open-ended probe: Tell me about the condition/disease. If the client has a personal history, probing questions might include: Timing: When did it occur? When were you diagnosed? Quality/quantity: How does it affect you? What symptoms do you have? Treatment: How is it treated? Is the treatment effective? Have you had any surgeries? (e.g., tonsillectomy or cancer-related surgeries or radiation?) Do you take medication? Provocative/palliative: Does anything make it worse? Does anything make it better? |
Although some lymphatic-related cancers involve familial clustering, the genetic causes are not clearly understood. Lymphedema is sometimes genetic (Jones & Mansour, 2017). This cause may be considered with childhood lymphedema, particularly when no cancers are present. |
Priorities of Care
In cases of severe lymphedema, you should assess for cellulitis, which is a bacterial infection resulting in fever and inflammation (heat, erythema, swelling, and pain) over the affected area. With severe infection, you may observe red, purple, or other deeply colored streaks radiating from the affected site (see Figure 10.4 for signs of cellulitis). Keep in mind that these streaks may be less visually obvious in clients with darker skin tones. Severe lymphedema is usually treated with antibiotics and can be life-threatening if untreated. Any signs of cellulitis should be reported to the physician or nurse practitioner. Mark the borders with a skin marker pen and monitor for enlargement. If the client is outpatient, tell them to contact their health care provider if it enlarges beyond the original borders.
Keep in mind that enlarged lymph nodes often simply indicate that the body is fighting an infection such as a cold. However, they are sometimes associated with serious conditions such as cancer, so you should always conduct a focused subjective and objective assessment when lymph nodes are enlarged. Any lymph node swelling with the following abnormal characteristics requires further investigation and should be reported to the physician or nurse practitioner:
- Nodes that are larger than 1 cm.
- Nodes that have developed for no apparent reason (i.e., no sign of infection) and remain swollen for more than 3 weeks or continue to enlarge.
- Nodes that are fixed/attached to the skin and not easily moveable.
- Nodes that are hard like a stone upon palpation or rubbery as opposed to soft.
- Nodes that are matted (in a group and attached to each other) as opposed to a discrete node (an individual node not attached to other nodes).
- Nodes associated with sustained symptoms such as fatigue, unexplained weight loss, persistent fever, fainting, and breathing issues.
Note whether nodes are non-painful or painful. Be aware that even a non-painful node may be a cause for concern: some non-painful nodes can meet some of the above characteristics and be associated with certain cancers. Nodes can also grow large enough to press on surrounding nerves. A systemic issue may be the cause of generalized swollen nodes found in multiple locations throughout the body, as opposed to localized. A local infected lymph node can also become systemic, so it is important to ask the client about symptoms such as fever, fatigue, chills, and anorexia.
Contextualizing Inclusivity
Children have active immune systems and are exposed to many viral and bacterial infections (e.g., cold, flu) at daycare and school. As a result, palpable soft, moveable, and small lymph nodes are common in children. These changes are the body’s normal response to fighting infection and indicate that the lymphatic system is working properly. Prompt assessment and intervention is required if the lymph nodes continue to enlarge when an infection has resolved or the swelling is associated with symptoms such as difficulty breathing or swallowing or any of the abnormal characteristics described in the box above.
Activity: Check Your Understanding
References
Jones, G., & Mansour, S. (2017). An approach to familial lymphoedema. Clinical Medicine, 17(6), 552-557. https://doi.org.10.7861/clinmedicine.17-6-552
