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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 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 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 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. Page 1 of 5 Documentation 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: 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 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. Page 2 of 5 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 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 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 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. Page 3 of 5 Contra- indications - As for intensive treatments above. Procedure 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 Assessment a) b) c) d) e) 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 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. Page 4 of 5 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 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 Page 5 of 5