Download Lymphoedema – Treatments including skin care and palliation

Guideline:
Lymphoedema – Treatments including skin care and palliation
The lymphoedema practitioner, following assessment of the patient, will determine an appropriate course of
treatment. Treatments can be intensive or maintenance and may comprise of Lymphoedema Bandaging Medical
Lymphatic Drainage (MLD), Simple Lymphatic Drainage (SLD), skin care and exercise or aimed at palliation of
symptoms.
Intensive treatments
Indications
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Excess volume > 20%
Distorted shape.
Digit swelling.
Skin folds.
Secondary skin changes.
Lymphorrhoea.
Consideration must also be given to age, impact of quality of life, patient’s wishes and motivation.
Contra-indications
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Cellulitis.( See guideline)
Arterial insufficiency.
Deep vein thrombosis.( see guideline)
Acute cardiac failure.
Shortness of breath or severe asthma.
Inability to remain safe during treatment when at home.
Process
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A course of intensive treatment will normally be arranged for 3 weeks.
Measurements will normally be taken for made to measure compression hosiery mid- treatment.
2 sets of garments will be provided to facilitate use 24 hours per day for the first 6 weeks to prevent rebound
oedema and to ensure that manufacturer’s guidelines for washing and usage can be adhered to.
The patient may be taught simple lymphatic drainage (SLD), together with an appropriate exercise regime, and
other aspects of care including skin care, will be reinforced.
Kinesiology tape may be used to support the intensive or maintenance phase of treatment and if used patients
will be taught self-application techniques as indicated. Ongoing management will need to be self-funded by the
patient as no Kinesiology tapes are currently available on prescription.
A follow-up appointment will be arranged for 4-6 weeks after completion of a course of treatment to review
progress.
Providing there are no complications or problems identified, the next appointment will be arranged at three to six
monthly intervals.
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Documentation
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Findings on assessment must be documented in the patient’s paper notes and each patient encounter on the
patient’s Electronic Health Record.
If there are any aspects related to the patient’s history that require clarification or further information prior to
implementing treatment, written details/consent must be obtained from the patient’s consultant.
Explanation should be given to the patient by the practitioner regarding the rationale for treatment and what is
required of them. This should be documented as above.
On completion of a course of treatment, the patient’s consultant, GP, other healthcare professionals, and the
patient if consented, must be informed in writing of the outcome.
Where findings indicate that intensive treatment is contra-indicated, this must be explained to the patient and
documented in the patient’s notes.
Where a patient is photographed before and after treatment, written consent will be obtained for each course of
treatment and retained in the patient’s notes and scanned to the Electronic Healthcare Record.
1. Lymphoedema Bandaging
Indications
Lymphoedema bandaging may carried out under the following circumstances:
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For chronic, severe or complex lymphoedema
Shape distorted limbs
Digit swelling
Lymphorrhoea
Skin folds
Secondary skin or tissue changes
A course of Lymphoedema bandaging should aim to reduce volume, improve shape, and improve tissue
consistency and minimise the risk of complications of chronic oedema. It is not a long term management plan in
itself but is a means to enabling maintenance therapy. In assessing which patients are suitable candidates for
Lymphoedema bandaging, consideration must be given to a patient’s age and health status, the impact
lymphoedema has on the quality of life, a patients expectations and their level of motivation and commitment
Contra-indications
As for intensive treatments above.
Procedure
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The length of the course will vary according to the patients underlying condition, clinical symptoms and
findings on assessment.
Three weeks of bandaging is recommended for patients with primary and in-active disease and secondary
lymphoedema
In Palliative disease, the patients’ general health condition and tolerance will need to be considered as the
aim of treatment for these patients should primarily be comfort.
In elderly patients with chronic venous insufficiency and where mobility is reduced, the treatment may need
to be adjusted to suit their needs and circumstances.
It is important for all patients that realistic goals of treatment are considered and are manageable within the
context of the patients’ social situation.
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Patients should be advised regarding care instructions appropriate to their particular bandages. Patients
having treatment with cohesive bandages such as Coban will be issued with a pair of disposable bandage
scissors to use ofr removal of bandages should the need arise. Made to Measure hosiery should be arranged
mid- treatment. Two sets of garments should be provided to enable them to be worn 24 hours per day for six
weeks post treatment if appropriate, and to ensure that manufacturer’s guidelines for washing and usage can
be adhered to.
2. Simple Lymphatic Drainage (SLD)
A recognised course teaching the principles of SLD has not yet been approved. Any junior member of staff must
initially work under the guidance of a senior practitioner.
Indications
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SLD can be used for facial, truncal , midline and limb oedema where the history and clinical findings indicate
that treatment would be appropriate
In advanced cancer, lymphatic drainage techniques may be used with careful consideration of disease status
and patient need.
Contra- indications
As for intensive treatments above.
Procedure
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SLD is only one component of a lymphoedema treatment programme and it should be explained to patients
that it is not an alternative to other recommended treatments.
SLD is useful following intensive treatments and in the maintenance phase and should therefore be
performed daily if appropriate
SLD should be is taught as part of an individual treatment plan.
Practitioners must adopt the same technique and provide information to the patient that is consistent across
practitioners.
If the patient is physically unable to perform SLD the technique can be taught to a partner / carer.
In the event of a cellulitic episode SLD should be discontinued.
SLD technique may be re-assessed at review appointments to ensure that technique is correct.
Written advice should be given to patients who have been taught this skill as a reference guide.
3. Medical Lymphatic Drainage ( MLD)
This technique aims to move lymphatic fluid from a congested area to an area with normal function via
recognised lymphatic pathways. This technique should only be performed by a lymphoedema practitioner who
has successfully completed a recognised MLD course and continues to meet the update criteria required to
practice MLD.
Indications
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Can be used within an intensive regime for lymphoedema, lipoedema and some other types of chronic
oedema.
Can be used for truncal, facial and midline oedemas as well as for limbs.
It can be used to aim to control oedema or to continue improvements within a maintenance therapy
programme.
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Contra- indications - As for intensive treatments above.
Procedure
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The length of treatment will vary according to a patient’s underlying condition, clinical symptoms and findings
on assessment.
If part of a course of intensive treatment MLD will be performed 2- 3 times per week when and where
resources allow. Thereafter the patient will be encouraged to continue with SLD as taught by the practitioner.
A Lymph-Assist pump may be used to simulate MLD of the limbs.
It should be explained to the patient that MLD is not an alternative to other recommended treatments and
should not therefore be used as a substitute treatment.
We will not offer MLD unless there is determined to be a clinical need for this. If patients do not have an
identifiable clinical need but wish to pursue this treatment privately they should be advised regarding
appropriate qualifications to look for when selecting a practitioner.
4. Skin Care
Skin care plays a vital role in the treatment of all patients with Lymphoedema or at risk of Lymphoedema. .Poor
skin integrity can have a direct detrimental effect on the risk of cellulitic infections. It is essential that the
practitioner gives the patient consistent and appropriate advice.
Procedure
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Assessment
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To observe for any signs of dryness or breaks in the skin.
To observe for any fungal infections, particularly between swollen digits or in the groin.
To observe for signs of infection; areas of redness or rash.
To observe for associated skin changes such as; hyperkeratosis, papillomatosis and
Lymphangoimata.
To observe for lymphorrhoea.
Advice should be given regarding daily basic care and supported with written information for reference.
Any skin changes determined in the assessment process should be considered when identifying individual
treatment plans or recommendations.
If appropriate a suitable emollient will be requested on prescription from the patients GP.
5. Exercise
Exercise should aim to achieve a balance between sufficient movement to avoid pooling of fluid in the tissues and
excessive strain on the limb.
Procedure
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The lymphoedema practitioner will encourage normal use of the limbs at all times.
When movement is painful or restricted, they should ascertain if this could be related to recurrence of
disease or other underlying pathology and refer to the appropriate healthcare professional for assessment.
An assessment should be carried out at the initial and subsequent appointments in order to establish the
patients’ range of movement and function.
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If the patient requires physiotherapy or an occupational therapy assessment they can be referred to the
hospice Physiotherapist and OT only if they are already in the care of Hospice in the Weald. All other patients
including those in the hospice catchment area, who are not known hospice patients, should have any
requests for referrals made via their GP or hospital consultant.
6. Palliative Care
The lymphoedema practitioner should differentiate between those patients who are able to manage active
treatment for their lymphoedema and those who require palliation of their symptoms.
The primary aim of treatment for patients requiring palliation of their lymphoedema is to optimise comfort and
to relieve symptoms as far as possible, recognising the limitations that the disease process may be imposing.
Procedure
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Assessment remains important but may not require as much detail as for other patients for example it is
acceptable to omit limb measurements if these would impact negatively on patient comfort or if limb
reduction is not a primary aim of care.
Oedema may be managed by good skin care, support of the limbs, European Class 1 or British standard class
1 or 2 garments.
Superior vena cava obstruction is a contra-indication for active treatment for lymphoedema although
treatment can be instigated with care if the patient has been stented.
Reduced mobility requires advice regarding support of the limbs and positioning in addition to the above.
Hosiery choices for patients with progressive disease should be made in consideration of prevention of
irritation or skin break down of cutaneous lesions/nodules. Hosiery should not be worn if it increases exudate
from fungating lesions, discomfort or pressure to any area of advancing disease. Support such as poly slings
should be considered to promote comfort when hosiery is not appropriate.
All findings and treatments must be documented in the Electronic Healthcare Record. The relevant
healthcare professionals within the hospice should be advised regarding any plan of care. For palliative
patients who are external to the hospice catchment area, relevant healthcare professionals such as DNs, GPs,
external CNS’ or staff at other hospices should be kept informed regarding care.
Date Originated:
Original Author:
May 2009
Kelly Nickson, Head of Lymphoedema Service
Date of Review:
Reviewed By:
January 2014
Kelly Nickson & Celia Garrett, Lymphoedema Clinical Nurse Specialists
Next Review Due:
July 2017
Issuing Authority:
Helen McGee, Consultant
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