Lymphatic System - Examination and Findings

Assessment of the lymphatic system should be completed as part of a comprehensive assessment, like during a routine physical exam, or as part of a focused exam if a client is experiencing issues such as lymphadenopathy, or enlarged lymph nodes. The lymphatic system provides the nurse with information about the integrity of the immune system, as well as the body's ability to regulate fluid and remove waste. Let's review the process of completing a lymphatic system assessment.

Okay, the supplies you'll need to assess the lymphatic system include a tongue depressor, pen light, and washable marker or pen.

Then, prepare for the exam by ensuring your client is in a comfortable position, that your hands are warm, and that the temperature in the room is comfortable. Provide privacy by closing the door and curtains, properly draping your client, and only exposing areas of their body as needed to perform your examination.

Before getting started, explain the procedure to your client and be sure to answer any questions they have before obtaining verbal consent. Then, perform hand hygiene and collect your supplies.

Locating the anatomical landmarks of the lymphatic system will help guide the placement of your equipment and hands throughout your assessment. To find the palpable lymph nodes in the head and neck region, start at the base of the skull to locate the occipital nodes. Then, move over the mastoid process to find the postauricular nodes, and then to the front of the ear to find the preauricular nodes.

Next, the parotid and tonsillar nodes are accessible at the angles of the mandible; the submandibular nodes are halfway between the tip and angle of the mandible; and the submental nodes are just behind the tip of the mandible.

Moving down the neck, locate the cervical nodes around the sternocleidomastoid muscle; the posterior cervical nodes along the anterior border of the trapezius muscle; and then move to the supraclavicular areas, which are in the angles between the clavicles and the sternocleidomastoid muscle, to locate the supraclavicular nodes.

Next, move to the upper extremities in the pocket of both axillae to assess the axillary nodes as well as in the space between the triceps and biceps muscles to find the epitrochlear nodes.

Lastly, in the lower extremities, locate the superior superficial inguinal nodes and inferior superficial inguinal nodes bilaterally in each groin, and the popliteal nodes, which exist in the popliteal fossae.

Alright, assessment of the lymphatic system includes inspection and palpation.

Okay, begin your assessment with inspection. Typically, you are not able to visualize lymph nodes or the lymph system. However, visible abnormalities of the lymphatic system usually fall into one of three categories: lymphadenopathy, which is enlargement of lymph nodes, lymphangitis, which appears as reddened lines on the skin, or lymphedema, which is swelling from an accumulation of lymph fluid in the tissues.

Start with the head and neck and move downward, inspecting each area of the body for visible lymph nodes, swelling, and redness.

Next, using a tongue depressor and pen light, inspect the tonsils and adenoids inside the oropharynx, noting their size, color, and shape. Both structures should be pink and symmetrical with an irregular surface.

If they're red, swollen, touching each other, covered with exudate, or if your client has a deviated uvula, this can indicate inflammation and infection. In children and adolescents, enlarged pink tonsils and adenoids can be a normal variation; and in some clients, the tonsils and adenoids are surgically absent.

Next up is palpation. Start with the head and neck and move downward, sequentially, from the head, to the neck, and then to the upper and lower extremities. Palpate with light pressure using the pads of the fingers to find superficial nodes and then gradually increase pressure to detect deeper nodes.

During palpation, feel for temperature, enlargement, firmness, tenderness, and mobility of the lymph nodes. Remember that in healthy adult clients, lymph nodes can range from 0.5 to 1 cm, and it's normal not to feel any superficial lymph nodes. If you do feel a lymph node, it should feel soft, mobile, non-tender, and equal bilaterally.

If you find enlarged lymph nodes, check for other abnormalities such as a node that's firm, fixed or non-movable, tender, or asymmetric.

Then, continue to explore the surrounding tissue for signs of infection or inflammation like redness, warmth, or a nearby wound which could be the source of an enlarged lymph node. Now, during your examination, you may find shotty nodes, which are small groupings of nodes, less than 1 cm, or 0.4 inches, which move when pressure is applied. These are generally a normal finding for clients who have recently had an infection. However, shotty nodes in the epitrochlear or supraclavicular regions should be reported to the healthcare provider as they could indicate possible thoracic or abdominal cancer.

On the other hand, if you find lymph nodes that are swollen and grouped together, these are called matted nodes, which can be present in clients with tuberculosis or Hodgkin disease.

If you find these, you should mark the borders of these lymph nodes with a washable marker and document their location and extent. In addition, if there's diffuse lymphadenopathy, it can be an indication of systemic disease, such as HIV infection or bacteremia. Also, it's important to note that rapid enlargement of lymph nodes, or a hard, painless, and fixed lymph node can suggest the presence of cancer, whereas slow enlargement over weeks or months is typically benign.

Lastly you should palpate the spleen for enlargement. To do this, you'll stand on your client's right side and put your left hand under them, touching the costovertebral angle, and then press upwards. Next, put the palm of your right hand on your client's abdomen below the left costal margin. Press your fingers inward towards the spleen and ask them to take a deep breath.

Normally, the spleen is not palpable, so if you feel it, it's probably enlarged, which is called splenomegaly. Splenomegaly may occur in clients infected with the Epstein-Barr virus, also known as mononucleosis, or in clients with sickle cell anemia or malaria.

As the nurse, it's your responsibility to correctly assess, interpret, report, and document your findings. If your assessment reveals something that's potentially abnormal or emergent, such as a painless, enlarged, non-movable lymph node, you should report this immediately to the health care provider, while monitoring client progress and changes from baseline.

Alright, as a quick recap….Assessment of the lymphatic system provides the nurse with information about the integrity of the immune system, as well as the body's ability to regulate fluid and remove waste. Supplies you'll need are a tongue depressor, pen light, and washable marker or pen. Assessment of the lymphatic system includes inspection and palpation. Lymph nodes are not usually visualized or palpable, but if you do feel a lymph node, it should feel soft, mobile, non-tender, and equal bilaterally. Any deviation from this should be further explored. As the nurse, it's your responsibility to correctly assess, interpret, report, and document your findings.