Lymphoedema and chronic oedema

• Chronic oedema prevalence increases with age and morbidity including poor lifestyle approaches, for example obesity.
• Untreated swelling often leads to skin changes, ulceration, cellulitis, and associated physical and psychosocial morbidity.
• Management strategies include addressing poor lifestyle choices, compression, skin care, and exercise, and should be centred around a self-care approach.
• There is a wide range of compression products available to prescribe, making it easier for community nurses to be involved in the management of these patients.
• Management of ulceration/lymphorrhoea/exudate that does not include compression is likely to result in prolonged input with poor outcomes and unnecessary cost implications.

Untreated chronic oedema and lymphoedema may advance, resulting in increased swelling and development of skin changes, and subsequently lead to associated physical and psychosocial morbidity (Haesler, 2016a). Compression can prevent the progression of these conditions and, in some cases, actively reduce the associated symptoms. In order to achieve this, compression products must be robust enough to prevent venous dilatation during walking or standing, promote absorption of tissue fluid into the lymphatic system, and improve venous and lymphatic flow (Partsch and Junger, 2006). Nurses now have a wide range of compression products available to prescribe for patients with lymphoedema or chronic oedema. This improved selection of hosiery and bandaging systems means a combined approach of preventative and active therapy can be achieved along the progression continuum of these conditions.

To ensure the correct hosiery or compression system is being prescribed, nurses need to be aware of the types and causes of

Function of the lymphatic system

The interstitial circulatory system comprises arterioles, venules and lymphatics. Oxygen and nutrients are delivered to the tissue cells via the arterial system and the waste products are removed by the venous system. The initial lymphatics absorb the tissue fluid and once filtered through the nodes, it is returned to the venous system either at the right or left subclavian veins. All the fluid is absorbed by the lymphatics (Mortimer and Rockson, 2014).

In lymphoedema, the fluid output from the arterioles into the interstitial space is normal but lymphatic uptake is reduced (Haesler, 2016b). Primary lymphoedema is caused by a congenital developmental fault in the lymphatics, which can be genetic. This can result in the presence of swelling at birth, or can be dormant for many years and develop later in life. Damage to the lymphatic system often results in the development of secondary lymphoedema. Lymphoedema

Chronic oedema is characterised by:

• swelling (usually in the legs) 
• exaggerated skin folds
• superficial ulceration
• exudate
• recurrent cellulitis.

Patients may suffer from one or all of the predisposing factors of chronic oedema, and are likely to have some or many compounding chronic co-morbidities, such as diabetes, arthritis, venous leg ulcers, and cardiovascular problems. As a result, these complex issues can have a devastating effect on the physical, psychological and social wellbeing of the patient (Elwell, 2016).

Physically, the swelling can cause a significant increase in the size of the legs and feet. This affects the ability to wear tighter-fitting clothing and most types of shoes. Any mobility problems are increased by the extra weight of the legs and with wearing ill-fitting or unsuitable footwear to accommodate the swelling.

Superficial ulceration can be very painful and lead to extensive exudate formation and increased risk of cellulitis. Skin changes in the form

A self-care strategy should always be the focus of the management of chronic oedema and lymphoedema. There are three main aspects to managing these conditions—preventative, self-care and intensive strategies. While there are differences in these two conditions, the range of interventions available overlaps including compression, which is vital for reducing oedema, improving skin changes and maintaining these outcomes (Table 1).

References

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