best practice for the management of lymphoedema ... - EWMA

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PSYCHOSOCIAL SUPPORT FIGURE 44 Algorithm to address psychosocial problems Generalist intervention Specialist intervention Depression According to severity of depression consider 48 : • • • • • • • • provision of information and support advice on sleep and anxiety management guided self help programme problem solving therapy cognitive behavioural therapy (short-term) counselling (short-term) antidepressant therapy referral to mental health services Refer to mental health services if 48 : • • • • • • • active suicidal ideas or plans psychotic symptoms severe agitation accompanying severe symptoms self-neglect poor or incomplete response to two interventions recurrent episode of depression within 1 year of last patient or relatives request referral Psychosocial support Psychosocial support is an important element of the holistic treatment of lymphoedema: it has the potential to have considerable influence on outcome by enhancing concordance, encouraging selfmanagement and maximising quality of life. Intervention involves planning and implementing psychosocial care strategies • • • • Poor concordance with treatment Assess why Improve communication Enhance patient involvement in care Repeat or modify treatment Patient has: that help patients and their family/carers to take a positive role in the management of their lymphoedema and to achieve as good a quality of life as possible (Figure 44). If psychosocial problems are not resolved within three months, the patient should be referred for specialist intervention. Loneliness and isolation Are the problems resolved in 3 months? No If low motivation due to depression Poor coping No further action required 48 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA No • • • • • Assess why Access patient support groups Arrange volunteer visitor Encourage family/carer involvement Institute financial/other measures No Refer to social worker Consider rehousing Consider home adaptations Yes • • • • • • Assess why Provide patient information Improve symptoms Arrange volunteer visitor Encourage family/carer involvement Increase professional support Refer for cognitive behavioural therapy Refer to psychologist
Palliative care The needs of patients with lymphoedema who are otherwise ill with advanced disease and who require palliative care can be complex. This document can provide only an indication of supportive measures and treatments that may be helpful. Lymphoedema can produce distressing and debilitating symptoms that affect lifestyle and function. Patients with advanced disease may not be able to tolerate a full programme of assessment and treatment, but require a palliative approach in which assessment techniques are modified and individual treatments are selected to ease specific symptoms (Box 37 and Table 9). TABLE 9 Management of lymphoedema in patients with palliative care needs Problem Unable to tolerate full assessment procedures Fragile or dry skin Discomfort in a swollen limb Swollen limb due to dependency or inactivity, or mainly venous oedema of lower limbs with no truncal oedema Severe limb or digit swelling Swelling of scrotum and/or penis Swelling of female genitalia Truncal oedema Lymphorrhoea Loss of independence and restricted mobility Intervention BOX 37 Guide to selection of treatment in advanced disease PALLIATIVE CARE ■ Ascertain type and cause of oedema, and contributory factors ■ Identify levels of symptoms such as pain ■ Establish significance of the swelling to the patient and consider patient circumstances and perspective ■ Establish realistic goals ■ Consider response to treatment ■ Use modified monitoring and limb volume measurement techniques ■ Maintain skin integrity – refer to skin management guidance ■ Reduced compression MLLB with modification to materials used ■ Low pressure compression garments ■ Good skin care and guidance on limb positioning ■ Gentle passive or active exercises ■ Reduced compression MLLB ■ Low pressure compression garment ■ IPC ■ Refer to physiotherapist ■ Good skin care ■ Reduced compression MLLB with modification to materials used ■ Close-fitting shorts with Lycra to provide scrotal support ■ Custom made garments and scrotal support for use by ambulant patients ■ Scrotal bandaging ■ Teach SLD ■ Lycra shorts with 1cm thick anatomically contoured foam pads ■ Flat knit custom made shorts with foam pads ■ Compression tights with localised padding ■ Teach SLD ■ MLD by practitioner with training at specialist level ■ Teach SLD ■ Supportive garments, eg bodice or bra for comfort ■ Good skin care and guidance on limb positioning ■ Modified reduced compression MLLB ■ Teach self care measures ■ Teach SLD ■ Refer to occupational therapist or physiotherapist as required ■ Appropriate psychological intervention ■ Low classification compression garments or shaped tubigrip if compression garments not tolerated BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA 49
Page 1 and 2: INTERNATIONAL CONSENSUS BEST PRACTI
Page 3 and 4: BEST PRACTICE FOR THE MANAGEMENT OF
Page 5 and 6: Introduction Lymphoedema is a progr
Page 7 and 8: Identifying the patient at risk C P
Page 9 and 10: C Patients Healthcare professional
Page 11 and 12: ASSESSMENT (a) (b) ■ micro-lympha
Page 13 and 14: ASSESSMENT BOX 12 Severity of unila
Page 15 and 16: ASSESSMENT FIGURE 3 Method for obta
Page 17 and 18: ASSESSMENT FIGURE 5 Stemmer sign In
Page 19 and 20: Treatment decisions B Patients with
Page 21 and 22: LOWER LIMB LYMPHOEDEMA - INITIAL MA
Page 23 and 24: FIGURE 7 Intensive therapy options
Page 25 and 26: FIGURE 8 Transition management - up
Page 27 and 28: MANAGEMENT OF MIDLINE LYMPHOEDEMA T
Page 29 and 30: FIGURE 13 Hyperkeratosis FIGURE 14
Page 31 and 32: Lymphangiosarcoma In the most sever
Page 33 and 34: Antibiotic regimens Antibiotic regi
Page 35 and 36: Intermittent pneumatic compression
Page 37 and 38: TABLE 5 Components of MLLB (in orde
Page 39 and 40: BOX 26 Principles of MLLB MLLB ■
Page 41 and 42: Addressing specific problems FIGURE
Page 43 and 44: Compression garments C Correctly fi
Page 45 and 46: (a) (b) Measurements required for a
Page 47 and 48: Checking fit A trained practitioner
Page 49 and 50: TABLE 7 Compression garment recomme
Page 51: Exercise/movement and elevation Exe
Page 55 and 56: Oxerutins have been licensed in som
Page 57 and 58: References 1. Badger C, Preston N,

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