Lymphoedema. Assessment and Management Theory to Practice Mary Costello, TVN,MScN Adv Practice, RNP.

Transcription

1 Lymphoedema Assessment and Management Theory to Practice Mary Costello, TVN,MScN Adv Practice, RNP.

2 Definition Lymphoedema manifests as swelling of one or more limbs.it is the result of accumulation of fluid and other elements in the tissue spaces due to an imbalance between interstitial fluid production and transport. Lymphoedema is a chronic condition that is not curable but it may be alleviated by appropriate management. (Lymphatic Framework,2009)

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4 Lymphatic/Venous System bath Lymph overflow pipe. 90% of circulatory fluid is dealt with by the lymphatic system. Arteries-tap Veins- majority of fluid goes out the plughole-venous system In venous disease, the plug hole is compromised therefore the overflow pipe helps out but eventually this too becomes compromised and the bath flows over into the interstitial tissues

5 Types of oedema 1.Lympho-venous oedema Staining to the skin,spider veins,leg shape distortion,swelling carries on up the limb 2.Dependancy oedema Impaired mobility impacts on venous return due to reduced calf muscle pump activity. 3.Lymphoedema Either primary(genetic) or secondary(traumatic) resulting from damage to the lymphatic system. 4.Lipoedema Abnormal deposition of fat cells in the lower limb.

6 Prevalence At birth,approx. 1 in 6000 will develop primary lymphoedema.milroys disease,present at birth and only affects the lower limbs. The overall prevalence of lymphoedema is estimated at0.13%-2% In developed countries the main cause of lymphoedema is widely assumed to be the treatment for cancer,12-60% prevalence reported in breast cancer,28-47% in patients treated for gynaecological cancer.

7 Classification of Lymphoedema Primary A result of congenital abnormality of the lymphatic system Secondary Results from damage to the lymph vessels and/or nodes due to trauma(mechanical, radiotherapy,lymph node excision,infection).may also result from venous insufficiency and overload.

8 Primary Lymphoedema

9 Lymph Pathways and Nodes

10 Assessment Medical Assessment Diagnosis is mostly established on history taking and clinical exam. Also,used to diagnose lymphoedema and exclude other aetiologies that may cause swelling ie.bloods,doppler u/s, lymphoscintigraphy.

11 Nursing Assessment 1.History Taking Family history congenital disposition History of cellulitis recurrent episodes can damage the lymphatic system History of swelling onset(slow or sudden),duration,what makes it worse or better,where does it extend to? Co-morbidities CHF,DVT,surgery or cancer treatment.

12 Nursing Assessment Physical Examination Inspection of Limb will identify: irregularities in limb circumference presence of ulceration varicose veins extent of limb involvement

13 Nursing Assessment Skin Inspection Dry skin may vary from slightly dry to scaly Hyperkeratosis horny scale build up with a warty appearance Papillomatosis warty growths on the skin consisting of dilated lymphatics and fibrous tissue Lymphorrhoea leakage of lymph through the skin Skin folds may cause development of fungal infections often seen where toes join the foot and in the presence of toe swelling the toes become square.

14 Nursing Assessment Palpation The Stemmers skin fold sign is an important diagnostic aid. The inability to lift a fold of skin at the base of the second toe is a positive Stemmers Sign and is indicative of lymphoedema.

15 Nursing Assessment Limb Circumference Baseline measurement to evaluate response to interventions. May be done using a tape measure at fixed points, usually at 4cm intervals from a fixed point at the ankle.

16 Nursing Assessment Psychosocial assessment Effect of swelling on day to day life Body image issues Expectation of treatment

17 Nursing Assessment Pain assessment Patients with oedema will experience pain and discomfort. To include, type of pain,location,current analgesia,exacerbating or alleviating factors. An evidence based pain scale should be used to record pain assessment.

18 Nursing Assessment Nutritional Assessment Lymphoedema is associated with obesity.obesity may contribute to the development of lymphoedema possibly by reducing mobility. BMI may indicate need for referral to dietician service re weight loss management.

19 Lymphoedema Management Aims of Treatment 1.To enhance lymphatic and venous flow 2.Swelling reduction and maintenance 3.skin care 4.Reduce risk 5.Pain management 6.Psychological management Successful management relies on the patient and carers playing an active role.

20 Aims1 and 2 Reduce limb volume and enhance lymphatic flow Compression bandaging using inelastic bandages(actico or Tensoplast). They create a massaging effect and stimulate lymph flow. Arterial compromise must first be ruled out via doppler ultrasound before compression bandaging is commenced. Frequency of bandaging is recommended daily for 5 days and then to reduce to 2-3 times weekly. If the toes are swollen then they will require bandaging. Training will be required. Bandaging may be applied either to the knee or thigh length depending on the extent of oedema.

21 Aims 1&2 contd Manual lymph Drainage is also a recommended component of treatment for lymphoedema(bls,2010). Presently in Laois/Offaly MLD is only available to clients with a secondary lymphoedema resulting from treatment for cancers, affecting lymph nodes.

22 Manual Lymph Drainage MLD is a large surface massage technique that uses skin contact to stimulate receptors, leading to a particular reaction in the skin, smooth muscle and the lymphatic system.

23 Manual Lymph Drainage Effects of; Calms the sympathetic nervous system Enhances the analgesic effect by affecting the the reflex pathways Immunological effect Enhances the efficiency of lymph flow by affecting smooth muscle Affects change in the connective tissue.

24 Complex Decongestive Therapy The Gold Standard for the treatment of lymphoedema includes 4 facets, which combined are referred to as CDT. MLD Compression Bandaging Exercise Skin Care

25 Aim 1 and 2 contd Following on from CDT the patient should be measured for a compression stocking. Patients should be measured for garments when swelling has been minimised,pitting oedema is absent or minimal and shape distortion is optimised. Made to measure garments are usually required and should only be measured and fitted by a trained practitioner. The level of compression garment recommended will depend upon the ABPI and the severity of lymphoedema.

26 Skin Care Wash skin daily using a soap substitute Ensure skin folds are clean and dry Apply emollients twice daily to aid rehydration Avoid scented products Monitor for fungal infections(moist,white scaling and itch).

27 Vision for the Future My vision for the development of a service for clients with Primary Lymphoedema involves; Completion of Therapy 2&3 Certification in Manual Lymph Drainage by end of Nov.2014 To commence the service with the commitment by a vascular consultant that our primary lymphoedema clients may be fast tracked for vascular assessment.

28 Vision for the Future contd. Liase with a multidisciplinary team, including dietician and physio for client referral To begin the service with a population of clients who are diagnosed with Stage 2 & 3 primary lymphoedema.

29 Other Therapies Intermittent Pneumatic compression Liposuction Surgical restoration of lymph flow Drug therapy benzopyrones(may stabilise swelling-little evidence of efficacy)

30 References British Lymphology Society Lymph Network(Europe) Lymphoedema Support Network(UK)