LYMPHOEDEMA

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• LYMPHOEDEMA
• Whats That?
• Lorina Nicholson
• Lymphoedema Nurse
• Luton and Dunstable
  Hospital
• Keech Hospice care

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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?
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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

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What is lymphoedema ?

• The lymphatic System
• Lymphoedema

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The lymphatic Systemhttp//web.ebscohost.com.lib
ezproxy.open.ac.uk/ehost/ebookviewer/ebook/nlebk_1
14775_AN?sid3a472ebe-e930-4f30-820b-e1bc2e545e65_at_
sessionmgr11vid1lpidlp_v
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Lymph Node
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• http//www.youtube.com/watch?vKh-XdNnTZUo

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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

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• 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)

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Categories

• Primary lymphoedema
• Secondary Lymphoedema

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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 doesnt
  exclude lymphoedema)
• Pain and sensation changes, i.e. tightness,
  heaviness

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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.

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Thickened skin with hyperkeratosis, papillomata
and deep skin creases in a lymphoedematous leg
(LSN)
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Papillomatosis
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Positive stemmer sign
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Severe Skin Changes
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Assessment

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

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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)

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How lymphoedema is managed

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

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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

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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)

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Juxta Fit
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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

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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

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Coban 2
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Coban 2
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Lymphatic Massage

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

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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

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

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Complications

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

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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

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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 _at_
  http//www.lymphoedema.org/Menu3/consensus_on_cell
  ulitis_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

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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

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• 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

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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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• Prevalence at end of life thought to be around
  5-10
• Oedema in advanced disease is often
  multifactorial in origin
• Need to assess if contributing factors can be
  improved as may influence overall management
• BE REALISTIC

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Principles of Care for the patient with end of
life lymphoedema

• Patient centred assessment and treatment plan,
  what appears problematic to the health
  professional may not be the patients first
  concern.
• Oedema assessment is part of overall specialist
  palliative care assessment
• Specialist palliative care professionals assess
  and treat non complex oedema if appropriately
  trained
• Aims include symptom control, improved quality of
  life, reduced risks due to oedema
• Involvement of family and caregivers
• Regular evaluation re benefits of treatment,
  changes in clinical condition
  (International
  lymphoedema framework 2010)

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• In advanced cancer oedema is particularly
  distressing for patients and their families
  because it signifies advancement
• It is a poor prognostic indicator
• Is a management challenge for health care
  professionals
• (International Lymphoedema framework,2010)

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• Thank You Very Much

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Further Information

• Lymphoedema Support Network http//lymphoedema.o
  rg/
• British Lymphology Society www.thebls.com/
• Consensus Document for cellulitis in lymphoedema
  available at
• http//www.lymphoedema.org/Menu3/consensus_on_cell
  ulitis_aug_10.pdf
• Lymphoedema Framework The Management of
  Lymphoedema in Advanced Cancer and Oedema at the
  End of Life
• Lymphoedema Framework. Best Practice for the
  Management of Lymphoedema. International
  consensus. London MEP Ltd, 2006.
• Both available at www.lympho.org
• Reducing the risk of upper limb lymphoedema
• http//www.rcn.org.uk/__data/assets/pdf_file/0003/
  403716/004138.pdf
• Drugs that may, exacerbate and those used to
  treat lymphoedema. Keeley, V. JOURNAL OF
  LYMPHOEDEMA 2008, 3(1)57-65 Pub United States,
  WOUNDS UK, 2008