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LYMPHOEDEMA What’s That? Lorina Nicholson Lymphoedema Nurse Lu

LYMPHOEDEMA What’s That? Lorina Nicholson Lymphoedema Nurse Luton and Dunstable Hospital & Keech Hospice care. ODY. IS IT TOO LATE??. NOBODY SAID ANYTHING ABOUT THE RISKS!. WHY DID NOBODY TELL ME?.

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LYMPHOEDEMA What’s That? Lorina Nicholson Lymphoedema Nurse Lu

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  1. LYMPHOEDEMA What’s That? Lorina Nicholson Lymphoedema Nurse Luton and Dunstable Hospital & Keech Hospice care

  2. ODY IS IT TOO LATE?? NOBODY SAID ANYTHING ABOUT THE RISKS! WHY DID NOBODY TELL ME? MAYBE I COULD HAVE DONE SOMETHING? HOW WAS LIVE WITH IT THEY SAID I SUPPOSED to know what TO DO?

  3. Objectives • What is lymphoedema? • Why is the patient at risk • Minimise the risk of developing lymphoedema. • Recognise signs and symptoms • Management • Management in palliative patients

  4. What is lymphoedema ? • The lymphatic System • Lymphoedema

  5. The lymphatic Systemhttp://web.ebscohost.com.libezproxy.open.ac.uk/ehost/ebookviewer/ebook/nlebk_114775_AN?sid=3a472ebe-e930-4f30-820b-e1bc2e545e65@sessionmgr11&vid=1&lpid=lp_v

  6. Lymph Node

  7. http://www.youtube.com/watch?v=Kh-XdNnTZUo

  8. Lymphoedema Lymphoedema is a swelling that develops as a result of an impaired lymphatic system. (LSN) (LSN Lymphoedema is a chronic progressive swelling, it results in the build up of fluid, protein and waste products in the tissues (Hardy, 2012) Your patient is at risk due to blockage, damage or removal of part of the lymphatic system, as part of cancer treatment or due to the cancer itself

  9. Lymphoedema is a chronic condition • Lymphoedema is not curable • Lymphoedema can be managed • If lymphoedema is ignored it may progress and become difficult to manage (Lymphoedema Framework, 2006)

  10. Categories • Primary lymphoedema • Secondary Lymphoedema

  11. Symptoms • Swelling, usually of an anatomically discrete region, pitting in early stages. • Skin changes: Thickened skin, deeper skin creases, Hyperkeratosis, Lymphangiectasia, Papillomata • Positive stemmer sign (lack of which doesn’t exclude lymphoedema) • Pain and sensation changes, i.e. tightness, heaviness

  12. Patients initial experience • clothing or jewellery (trouser leg, sleeves or rings) feeling much tighter than usual • noticeable sensations of heaviness, stiffness, • tightness or fullness in the arm, hand or shoulder, leg • the arm or leg aching more than usual • noticeable swelling, though initially this may come and go and will often be worse at the end of the day.

  13. Thickened skin with hyperkeratosis, papillomata and deep skin creases in a lymphoedematous leg (LSN)

  14. Papillomatosis

  15. Positive stemmer sign

  16. Severe Skin Changes

  17. Assessment History • Duration? • Site? • Pain? • Co morbidities? • Temporal variation? • Family history? • Drugs? (see Keeley, 2008) • Eliminate Thrombosis/Cellulitis/spread

  18. Minimising the risk of developing lymphoedema Recognise the risk/Remember the risk is life long Normal use, muscular activity encourages lymph drainage, avoid sudden over-exertion such as carrying heavy objects. Hygiene Skin Care Avoidance of trauma Unless there is a medical emergency, avoid taking blood pressure measurements, injections or blood samples from the ‘at risk’ limb as this may lead to infection and/or the onset of lymphoedema.(RCN, 2011)

  19. How lymphoedema is managed 4 cornerstones • 1.Skin Care • 2.Exercise • 3.Compression • 4.Lymphatic Massage And sometimes: lymphoedema taping, low level lazer, pumps

  20. Skin Care • Aim to keep the skin in optimum condition and intact • Hygiene, wash daily, care of skin folds • Soap substitute • Emollients • Observe indications of skin changes, • Treat breaks with antiseptic

  21. Compression Garments • Long term management of Lymphoedema • Circular knit: material continually knitted on a cylinder, more give than a flat knit. • Flat knit: firmer thicker fabric with a seam, firmer working pressure • Come in different classes which reflect the sub hosiery pressure (mmHg)

  22. Juxta Fit

  23. Multilayer Lymphoedema Bandaging • Indications for MLLB (from the Best Practice Document) • Lymphoedema with: • ■ fragile, damaged or ulcerated skin • ■ distorted limb shape • ■ limb too large to fit compression garments • ■ areas of tissue thickening • ■ lymphorrhoea • ■ lymphangiectasia • ■ pronounced skin folds

  24. Materials • Cotton tubular bandage • Toe bandages (if indicated) – 4cm conforming bandage • Soft synthetic wool or soft foam roll (10cm or 20cm) • Inelastic bandages – one 8cm, three to four 10cm for lower leg, and four to six 12cm for thigh

  25. Coban 2

  26. Coban 2

  27. Lymphatic Massage • Manual Lymphatic Drainage (MLD) • Simple Lymphatic Drainage (SLD) Aims to reduce swelling by encouraging lymph flow

  28. Indications for MLDand SLD • Swelling at the root of a limb • Trunk and midline oedema(eg chest, breast, back,abdomen, genitalia, head and neck) • Provision of comfort and pain relief when other physical therapies are no longer appropriate • Adjunctive treatment to pain management

  29. MLD alone is not sufficient treatment for Lymphoedema (Lymphoedema Framework, 2006)

  30. Complications Cellulitis Lymphorrhoea Skin changes Dry skin • Hyperkeratosis, • Lymphangiectasia, • Papillomata • Fungal infections

  31. CellulitisInfection of the skin/tissues • Symptoms: an acute, spreading inflammation of the skin and subcutaneous tissues and is associated with pain, swelling and erythema, sometimes with severe systemic upset, with high fever and rigors

  32. Cellulitis Treatment: Avoidance by maintaining skin integrity • should be treated immediately using appropriate antibiotics • Consensus Document for Best Practice for Cellulitis in Patients with Lymphoedema @ http://www.lymphoedema.org/Menu3/consensus_on_cellulitis_aug_10.pdf • Oral amoxicillin 500mg 8-hourly and or flucloxacillin 500mg 6-hourly for no less than 14 days • Remove compression until inflammation has reduced • Analgesia e.g. Paracetamol • Rest • Elivate • Monitor

  33. Lymphorrhea • Occurs when lymph leaks from the skin surface • Area around leakage can become macerated • Distressing for the patient and family • Portal for infection/cellulitis

  34. Review, determine cause • Protect surrounding skin with emollient • Non adherent absorbent dressing (initially will need very frequent changing) • Reduce underlying lymphoedema with multilayer lymphoedema bandaging • Elevate if possible • Monitor for deterioration

  35. Management in palliative patients Palliative care aims: Provide relief from all symptoms Support the individual to live as actively and independent as possible until death WHO

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