Lymphoedema is a chronic and progressive disorder resulting from impaired lymphatic system function, triggering an excessive accumulation of lymph fluid in the superficial tissues that can lead to chronic swelling, localised pain, atrophic skin changes and secondary infections (Whitaker, 2016; Kayiran et al, 2017). Lymphoedema can be primary or secondary in aetiology. The former is related to developmental abnormalities of the lymphatic system, whereas the latter is attributed to the impairment of lymphatic vessels because of an acquired condition, such as trauma, tumour, surgery or infections (Kayiran et al, 2017).
To date, there is no cure for lymphoedema. The condition is associated with impaired quality of life, both in terms of psychosocial and physiological functioning, with pain, skin tightness, heaviness, numbness and reduced range of movement reported, as well as altered body image, anxiety and depression (Thomas et al, 2020). A study on the impact of lymphoedema on employment highlighted that 80% of patients were absent from work; 9% changed their employment status; 2% switched jobs; and 8% gave up work completely (Moffatt et al, 2003). Therefore, it is imperative to collaborate with the patient to create and maintain an effective management strategy.
The recommended treatment of lymphoedema is based on decongestive lymphoedema therapy, which has two phases: an intensive phase, combining manual lymphatic drainage (MLD), multi-layer bandages, skin care and physical exercises to reduce volume; and a maintenance phase, which involves helping the patient to preserve the reduced volume achieved during the intensive phase for as long as possible (Mestre et al, 2017). This second phase is accomplished through the use of compression garments, such as bandages, stockings and wrap systems. The accessibility and relative simplicity of many of the methodologies used to manage lymphoedema mean that, while the impact on quality of life is often significant, people with this condition commonly achieve a great deal of autonomy in their own care, with the support of community nurses. Therefore, nurses can make a real difference in lymphoedema care by equipping patients with the necessary information about their condition and providing practical support to enable self-management. Nurses in the community can facilitate improved outcomes and quality of life.
Management methodologies
While not all nurses are lymphoedema specialists, they can still play a part in helping patients understand the complexities associated with lymphoedema by accessing up-to-date training and resources, and ensuring that they are confident in providing advice and guidance. Some of the most important components of a lymphoedema management strategy are discussed in this article, providing a foundational knowledge to share and discuss with patients.
Compression
There are a variety of compression delivery systems, summarised in Table 1. The best option depends on the needs of the patient; however, lymphoedema generally requires a higher pressure to return the fluid from the limb's tissues, with up to 60 mmHg pressure at times to achieve reduction (Payne, 2024). While compression garments were traditionally used consistently to reduce lymphoedema, patient concordance is often a challenge with this option. Patients may find well-fitted garments difficult to put on difficulty applying and removing compression hosiery can also increase the risk of skin damage, with the need for daily application and removal of hosiery to allow skin care contributing to this risk (Payne, 2024).
| Type of compression system | Indications | Advantages | Disadvantages |
|---|---|---|---|
| Circular-knit garments | Chronic oedema | Cosmetically pleasing | May cut into skin folds |
| Venous disease | Promotes self-care | Less easy to apply | |
| Less expensive than flat knit | |||
| Flat-knit garments | Chronic oedema with shape distortion or fatty limbs | Better at bridging skin folds | Less cosmetically pleasing |
| Easier to apply | More expensive than circular knit | ||
| Promotes self-care | |||
| Short-stretch compression bandaging | Reducing oedema | Provides high-working and low-resting pressures | Time consuming; requires 2–5 changes per week |
| Improving shape | Some bandages can be reused, thus reducing cost | Bulky for use with footwear | |
| Improving skin changes | Reduces self-care | ||
| Lymphorrhoea | |||
| Long-stretch bandaging | Venous leg ulcers | Weekly change | Bulky for use with footwear |
| Best practice for healing venous leg ulcers | Reduces self-care | ||
| Velcro wrap | Chronic oedema | Can be used alone or as an adjunct to compression garments | Requires dexterity to apply |
Compression wraps can present a suitable alternative, overcoming many of the obstacles encountered in the use of compression garments, as they are made from inelastic fabric, wrapped around the limb and secured in place by strips of Velcro and stitched or secured into a single garment at the back of the limb. Application is relatively easy and does not require specialist training, allowing patients to self-apply and remove or re-adjust as needed (Payne, 2024). Wraps made from double-layered material have been found to provide greater mean pressure than those made from single-layered material; therefore, wraps made from double-layered material are recommended for lymphoedema management (Payne, 2024).
Skin care
The affected limb should be washed, dried and moisturised daily; a pH-neutral skin cleanser should always be used because of the dehydrating effect soap can have on the skin (Payne, 2024). The skin of a swollen limb is already under strain, so it is important to prevent damage—for instance, the limb should be patted dry, rather than rubbed. The use of emollients can help restore lost moisture and maintain the skin's elasticity and barrier function (Payne, 2024).
It is relatively easy to teach patients and carers about skin care as part of their self-management efforts, but nurses should also be cognisant of instructing patients about the importance of skin inspection as part of their self-care regimen. Skin inspection is a preventative measure that allows the early identification of potential issues. Individuals with lymphoedema should be encouraged to inspect the skin for redness, scratches, abrasions or cuts on a daily basis; inspect skin folds for excoriation or fungal infection; and report signs of bacterial or fungal infection (including pain) to a clinician for early management (Haesler, 2016). Patients should be particularly vigilant for specific skin changes related to certain conditions, such as hyperkeratosis and papillomatosis (Payne, 2024).
Lymphatic drainage
MLD comprises certain movements of the hand to stretch the skin in a specific direction and to promote variations in interstitial pressures, aimed at enhancing the filling and emptying of lymph vessels (Provencher et al, 2021). These movements are slow, repetitive and usually incorporate a brief resting phase, allowing the skin to return to its initial position. This skin stretching and resting combination is reported to be effective on lymph collectors and local smooth muscles (Provencher et al, 2021).
While MLD is often performed by a skilled practitioner, patients can be taught a simplified version known as self or simple lymphatic drainage (SLD). The British Lymphology Society (BLS) (2022) believes there is value in MLD and SLD as they may provide psychological and symptomatic relief, even if the efficacy of MLD and SLD has not been definitively proven. SLD is encouraged as it helps to maintain the benefits of intensive treatment and encourages continued flow of fluid through pathways identified by the therapist as the most beneficial. SLD should be performed at least once a day for 10–20 minutes and in areas where swelling is not present. Only light pressure should be applied; sufficient pressure is firm enough… firm enough to induce stretching of the skin, but light enough to avoid indentation, leaving no evidence of redness (BLS, 2022). Cream, talcum powder or cornflour may be used to facilitate hand movement across the skin (BLS, 2022).
Written instructions and access to videos of the sequence used in SLD may help the individual or carer learn the skill; this self-management technique should be supported by regular review by the attendant nurse or during the patient's visit to a lymphoedema clinic. The International Lymphoedema Framework provides access to numerous short films, including SLD of the upper and lower limb; the Lymphoedema Support Network also has leaflets, DVDs and online films available, which explain what SLD is and how to perform SLD of the upper and lower limbs (BLS, 2022).
Conclusions
Alongside clinical support, psychosocial support of the lymphoedema patient comprises an important part of the community nurse's role, with promotion of patient self-management being imperative. Other aspects related to self-management that the community nurse might be expected to support in relation to self-management include: exercise, weight management, certain treatment modalities and the condition's impact on a patient's confidence, body image and quality of life.
The emphasis of lymphoedema care, alongside management of the condition, must be on empowering the patient while successfully controlling their oedema, enabling them to take back control. With their wide breadth of expertise and ability to leverage the therapeutic relationship, community nurses are ideally placed to make a real difference in this domain.