General characteristics
Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skin fold, umbilicus. (See Descriptor reference.) (more…)
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Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skin fold, umbilicus. (See Descriptor reference.) (more…)
Read MoreImagine you have a health condition that affects your life every day. Then imagine being told nothing can be done about it; you’ll just have to live with it. Or worse yet, your physician tells you the problem is “you’re just fat.”
Many people with lymphedema or lipedema have no idea their condition has a name or that many other people suffer from the same thing. Although lymphedema and lipedema can’t be cured, proper management and resources can help patients cope. This article improves your grasp of these conditions, describes how to recognize and manage them, and explains how to support your patients.
To understand lymphedema and lipedema, first you need to understand how the lymphatic system functions. It makes lymph, then moves it from tissues to the bloodstream. It also plays a major role in the immune system, aiding immune defense. In addition, it helps maintain normal fluid balance by promoting fluid movement from the interstitial tissues back to the venous circulation. (See Lymphatic system: Four major functions.)
If the lymphatic system is impaired from a primary (hereditary or congenital) condition or a secondary problem, lymphedema can result. In this chronic, potentially progressive, and incurable condition, protein-rich fluid accumulates in the interstitial tissues.
Lymphedema occurs in four stages.
Stage 0. During this stage (also called the subclinical or latency stage), transport capacity of the lymphatic system decreases but remains sufficient to manage normal lymphatic loads. Signs and symptomsaren’t evident and can be measured only by sensitive instruments, such as bioimpedance spectroscopy and optoelectronic volumetry. Without such instruments to quantify volume changes, diagnosis may rest on subjective complaints.
In this stage, limited functional reserve of the lymphatic system leads to a fragile balance between subnormal transport capacity and lymphatic loads. Added stress on the lymphatic system (as from extended heat or cold exposure, injury, or infection) may cause progression to stage 1.
Providing appropriate patient information and education, especially after surgery, can dramatically reduce the risk that lymphedema will progress to a more serious stage.
Stage 1. Considered the spontaneously reversible stage, stage 1 is marked by softtissue pliability without fibrotic changes. Pitting can be induced easily. In early stage 1, limb swelling may recede over – night. With proper management, the patient can expect the extremity to decrease to a normal size compared to that of the uninvolved limb. Otherwise, lymphedema is likely to progress to stage 2.
Stage 1 lymphedema may be hard to distinguish from edemas from other causes. Clinicians must rely on the patient history and monitor for swelling resolution with conventional management, such as compression and elevation, or note if swelling persists despite these standard interventions.
Stage 2. Sometimes called the spontaneously irreversible stage, stage 2 is identified mainly from tissue proliferation and subsequent fibrosis (called lymphostatic fibrosis). The fluid component can be removed spontaneously, but removal of the increased tissue proliferation (initially irreversible) takes more time. Tissue proliferation stems from long-standing accumulation of protein-rich fluid; over time, the tissue hardens and pitting is hard to induce. In many cases, swelling volume increases, exacerbating the already compromised local immune defense.
Consequently, infections (particularly cellulitis) are common; these, in turn, increase the volume of the affected area. Proper treatment can reduce volume.
With proper care (complete decongestive therapy [CDT]), lymphedema can stabilize during stage 2. But patients with chronic or recurrent infections are likely to progress to stage 3.
Stage 3. Also called lymphostatic elephantiasis, this stage is marked by further fluid volume increases and progression of tissue changes. Lymphostatic fibrosis becomes firmer and other skin alterations may occur, including papillomas, cysts, fistulas, hyperkeratosis, fungal infections, and ulcers. Pitting may be present. Natural skinfolds deepen (especially those of the dorsum of the wrist or ankle) and, in many cases, cellulitis recurs.
If lymphedema management starts during this stage, reduction can still occur. Even in extreme cases, with proper care and patient adherence to treatment, lymphostatic elephantiasis can be reduced so the leg is a normal or near-normal size.
A thorough physical examination is the gold standard for diagnosing lymphedema. A complete patient history, body-systems review, inspection, and palpation can help determine if edema is lymphedema.
Clinically, the only test with proven reliability and validity in diagnosing lymphedema is the Stemmer sign. Fibrotic changes associated with lymphedema can lead to thickened skin over the proximal phalanges of the toes or fingers. If you can’t tent or pinch the skin on the involved extremity, lymphedema is present (a positive Stemmer sign). However, a negative finding (soft, pliable tissue) doesn’t rule out lymphedema because the condition may be in an early stage, before tissue proliferation and fibrosis have set in.
Although incurable, lymphedema can be managed successfully through CDT. This approach involves proper identification of lymphedema, manual lymph drainage, skin and nail care, patient education, compression, and exercise.
CDT has two phases:
• Phase I, the intensive phase, continues until the extremity has decongested or reached a plateau. The clinician provides treatments and educates the patient about all aspects of CDT to prepare him or her for phase II. Phase I can last several weeks to several months depending on lymphedema severity.
• Phase II, the maintenance phase, begins once the extremity has decongested or plateaued. This phase still focuses on CDT, but now the patient, not the clinician, is responsible for all care. The goal is to reduce limb size while enabling the patient to become self-sufficient in managing lymphedema. Although CDT can bring significant improvements in limb size, skin quality, and function, patients must remember that phase II continues lifelong. Be sure to provide education about ongoing self-management strategies.
Lipedema is a painful disorder of fat deposition. Pathologic deposition of fatty tissue (usually below the waist) leads to progressive leg enlargement. Like lymphedema, lipedema is incurable but manageable. Unless managed properly, lipedema can reduce mobility, interfere with activities of daily living, and lead to secondary lymphedema. (See Lipedema stages.)
Lipedema commonly is misdiagnosed as lymphedema. However, lymphedema involves protein-rich fluid, whereas lip edema is a genetically mediated fat disorder. Because lipedema resists diet and exercise, it can lead to psychosocial complications. Lipedema occurs almost exclusively in women; typically, onset occurs between puberty and age 30. One unpublished epidemiologic study puts lip edema incidence in females at 11%. Some patients have a combination of lipedema and lymphedema. (See Viewing lipolymphedema.)
As with lymphedema, lipedema diagnosis rests on clinical presentation. Lipedema characteristics include bilateral and symmetrical involvement, absence of pitting (because lipedema isn’t a fluid disorder), soft and pliable skin, and filling of the retromalleolar sulcus (called the fat pad sign.)
Key signs and symptoms include:
• feeling of heaviness in the legs (aching dysesthesia)
• easy bruising
• sensitivity to touch (called “painful fat syndrome”)
• orthostatic edema
• oatmeal-like changes to skin texture.
Nearly half of lipedema patients are overweight or obese, but many appear of normal weight from the waist up. Essentially, the upper and lower extremities don’t match. The lower extremities typically show fatty deposits extending from the iliac crest to the ankles, sparing the feet. (See Lipedema patterns.)
Lipedema is best managed through weight control, as additional weight gain through adipose tissue tends to deposit in the legs. For patients with concomitant lymphedema (lipolymphedema), modified CDT helps reduce and manage lymphatic compromise. To address excess fat deposition, newer “wet” liposuction techniques have proven beneficial. These techniques gently detach adipose cells from the tissue, helping to preserve connective tissue and lymphatic vessels.
In both lymphedema and lipedema, early identification and proper diagnosis are key. (See Differentiating lymphedema and lipedema.) A thorough history and physical exam will likely lead to an accurate diagnosis, if clinicians know what to look for. Proper diagnosis and treatment can prevent expensive and ineffective interventions, which can negatively affect both the patient’s condition and psychological well being.
Heather Hettrick is an associate professor at Nova Southeastern University, Department of Physical Therapy in Fort Lauderdale, Florida.
Fat Disorders Research Society. Lipedema description.
Fife CE, Maus EA, Carter MJ. Lipedema: a frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care. 2010;23(2):81-92
Herbst KL. Rare adipose disorders (RADS) masquerading as obesity. Acta Pharmacol Sin. 2012;33(2):155-72.
National Lymphedema Network. Position papers.
Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. 2012;166(1):161-8.
Zuther J. A closer look at lipedema and the effects on the lymphatic system. December 13, 2012. lymphedemablog.com/2012/12/13/a-closer-look-at-lipedema-and-the-effects-on-the-lymphatic-system/
Zuther J. Stages of lymphedema. October 3, 2012.
Read MoreInappropriate footwear is the most common source of trauma in patients with diabetes. Frequent and proper assessment of appropriate footwear is essential for protecting the diabetic foot from ulceration.
Here is a step-by-step process for evaluating footwear. Be sure to evaluate footwear with the patient walking, standing, and sitting. (more…)
Read MoreThis issue we focus on resources to help clinicians protect themselves from injuries and engage in a healthier lifestyle.
A hospital is one of the most hazardous places to work, according to the Occupational Safety and Health Administration (OSHA). The agency provides a wealth of information on how to protect hospital workers as part of its website Worker Safety in Hospitals: Caring for Our Caregivers. PDF resources include:
• A fact sheet that helps dispel myths, barriers, and concerns related to safe patient handling
• Information on making the case for safe patient handling programs (more…)
Read MoreUsing maggots to treat wounds dates back to 1931 in this country. Until the advent of antibiotics in the 1940s, maggots were used routinely. In the 1980s, interest in them revived due to the increasing emergence of antibiotic-resistant bacteria.
At Select Specialty Hospital Houston in Texas, we recently decided to try maggot therapy for a patient with a particularly difficult wound. In this case study, we share our experience. (more…)
Read MoreA study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.
“The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.
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Optimizing nutritional status is a key strategy both in preventing and managing pressure ulcers. In patients across all care settings, compromised nutrition— as from poor intake, undesired weight loss, and malnutrition—increases the risk of pressure ulcers. It contributes to altered immune function, impaired collagen synthesis, and decreased tensile strength. In many cases, malnutrition also contributes to wound chronicity and increases the risk for delayed and impaired wound healing. In patients with chronic wounds, such as pressure ulcers, a chronic inflammatory state can induce catabolic metabolism, malnutrition, and dehydration. (more…)
Read MoreSupport surfaces are consistently recommended for the prevention and treatment of pressure ulcers. So patients can derive optimal benefits from support surfaces, clinicians must understand how to use them effectively. This article answers several questions about these useful tools. (more…)
Read MoreA five-session ostomy self-care program with a curriculum based on the Chronic Care Model can improve health-related quality of life (HRQOL), according to a study in Psycho-Oncology.
“A chronic care ostomy self-management program for cancer survivors” describes results from a longitudinal pilot study of 38 people. Participants reported sustained improvements in patient activation, self-efficacy, total HRQOL, and physical and social well-being. Most patients had a history of rectal cancer (60.5%) or bladder cancer (28.9%). (more…)
Read MoreKeeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild on Wounds (WOW) conference held each September in Las Vegas. Every year, I present the opening session, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.
In the January issue, I discussed some of the updates from my 2015 Buzz Report. Now I’d like to share a few more, along with some of my favorite resources. (more…)
Read MoreDeveloping a pressure ulcer can cause the patient pain, lead to social isolation, result in reduced mobility, and can even be fatal. According to the Agency for Healthcare Research and Quality, estimated costs for each pressure ulcer range from $37,800 to $70,000, and the total annual cost of pressure ulcers in the United States is an estimated $11 billion.
Nurses understand their role in preventing pressure ulcers, but what role do patients play in the prevention plan? Nurses need to empower the patient to be an active member in health promotion activities and participate in prevention measures. In this article, I highlight the importance of incorporating pressure ulcer prevention into patient education for high-risk patients as a way to empower patients. Empowered patients can help improve outcomes and reduce overall costs of this hospital-acquired complication. (more…)
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