Nursing measures for lymphoedema in gynaecologic cancers
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.19187
Source of Support: None, Conflict of Interest: None
Keywords: lymphoedema, gynaecologic cancer, simple lymphatic drainage
Lower limb lymphoedema after treatment of gynecologic cancer is a potentially disfiguring chronic condition that can have significant physical, psychological and social consequences for the affected individual.
Physical disabilities include sensory disturbances in the swollen limb, heaviness, pain, fragility of skin, and joint complications leading to impairment in activities of daily living. Disfigurement and disability can cause increased anxiety, depression, adjustment problems, reduced sexual drive and negative body image, marital disharmony, social inhibition and isolation.
This article outlines low cost measures that palliative care nurses in India can use to help patients with lymphoedema. Compression garments and manual lymphatic drainage will not be discussed here.
The lymphatic system collects the excess fluid and protein from the interstitial space and drains into the vascular compartment. This protein rich fluid is propelled against gravity through the lymph vessels by the pressure gradient caused by breathing movements, skeletal and smooth muscle contraction.
Lymphatics of the uterus begin in three intercommunicating networks - endometrial, myometrial, and subperitoneal. These vessels drain into lymphatics on the side of the uterus.
The upper lymphatics drain the fundus and upper part of the body of the uterus into the paraaortic groups of nodes. The cornu drains into the superficial inguinal gland along the round ligament. The middle lymphatics drain from the lower part of the uterine body into the external iliac nodes. The lower lymphatics drain the cervix, and pass (i) laterally in the parametria into external iliac and obturator lymph nodes either directly or through paracervical lymph nodes, (ii) posterolaterally in to the internal iliac group, (iii) posteriorly into the sacral group.
These vessels drain into the lumbar lymphatic trunk which joins the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties in to the left subclavian vein.
Lymphoedema occurs when lymph transport is impaired leading to stagnation of fluid in the interstitial spaces. Primary lymphoedema due to intrinsic abnormalities of the lymphatic system is also known as (Milroy's disease). Secondary lymphoedema results from damage or obstruction of the lymphatic system due to a variety of causes. These include surgical removal of lymph nodes, infection, cancer spread or post treatment fibrosis.
Patient education is critical both for prevention and management of lymphoedema. Presented below is an instruction leaflet prepared for use with lymphoedema patients in resource poor settings. The material is adapted from Bellhouse.
What is lymphoedema?
Lymphoedema is the accumulation of lymphatic fluid beneath the skin-which causes swelling of the limb. This happens if the lymphatic system is damaged or blocked or if there are not enough lymph vessels.
What is the treatment?
Although it is impossible to remove the scarring or damage done to lymphatics, lymphoedema can be controlled.
The treatment includes the following
4.Simple lymphatic massage
Looking after your skin is an important part of your treatment. Swollen arms and legs are particularly prone to infection. Dry, cracked skin allows the entry of germs.
Instruction for skin care
•Wash the affected arm with luke warm water.
•Do not use too much soap which will dry the skin.
•Dry it using a towel; Do not rub.
•Apply coconut oil from the fingers upwards four times daily.
•It is better to avoid jewellery on the affected arm.
•Avoid injury to the arm/leg.
•Use loose clothing.
•Avoid injections in the swollen arm, including blood sampling.
•Avoid blood pressure measurements on the swollen arm.
•Take care when cutting toe or finger nails; use a nail cutter.
•Wear gloves while doing house hold work.
•Treat cuts, scratches, insect bites promptly by cleaning well and applying antiseptic cream or solution.
•Seek medical aid if the skin becomes red and swelling increases.
Elevate the swollen arm or leg while lying down using pillows or other aids.
When sitting the legs should be raised at level with your hips. Do not dangle your legs if swollen; avoid crossed legs.
Exercise plays an important part in encouraging fluid drainage since the muscles help to pump lymph out of the limb. Gentle regular exercise is required. Try to do the following exercise every morning and evening.
Do not strain while doing the exercises. Do exercises which are within your ability.
These exercises are best done lying on a bed or floor with the legs raised on pillows or cushions.
Slowly and firmly bring knees upto chest.
Slowly straighten legs and lower down to pillows. Repeat 10 times.
Slowly and firmly point foot towards floor then bring back as far as it will go. Repeat 10 times.
Slowly and firmly rotate feet making circular movements with pointed toes. First clockwise then anticlockwise. Repeat 10 times.
Bring knees upto chest and slowly an firmly do bicycling movements. Repeat 10 times.
Place hands on top of head then slowly bring down to touch shoulders. Repeat 10 times.
Place hands behind neck then slowly bring hands down behind the waist. Repeat 10 times.
Slowly and firmly strengthen arm, then bend at elbow till it go no further. Repeat 10 times.
Slowly an firmly clench and unclench fingers. Repeat 10 times.
Lie flat on bed. Clasp hands together and left arms straight up as far as they will go. Repeat 10 times.
Massage is used to encourage fluid away from swollen, congested areas of the body to areas where it can drain away normally.
Areas over lymph nodes are massaged.
Always start away from the swollen area moving back towards the swollen limb, always massaging fluid forwards towards the lymph nodes.
The session begins and finishes with a short breathing exercise which helps to clear the deep lymphatic system.
Massage using your finger pads.
Massage yourself, if not possible a close relative can do it. If the swelling increases or the limb becomes red, seek medical aid.
To improve drainage from the am
Remove your clothes. Lie down or sit comfortably. Take a deep breath hold it for few seconds and breathe out through your mouth. Repeat 10 times.
Massage both sides of the neck below the ears. Take the skin back and then circle down towards the shoulder. Repeat 10 times.
Massage both sides of neck between ears and shoulders. Repeat 10 times.
Massage the area between the collar bone and shoulder movement is towards the neck. Repeat 10 times.
Massage the axilla 10 times. Pushing fluid toward the back.
Massage the upper chest wall 10 times.
Massage the back 10 times.
Do the deep breathing exercise 10 times.
To improve drainage from the leg
Do all the massage as for the arm drainage.
Massage inner aspect of the upper thigh. Repeat 10 times.
Massage top of the thigh. Repeat 10 times.
Massage the lower abdomen with direction towards axilla. Repeat 10 times.
Massage lower back. Repeat 10 times. Complete with breathing exercise Relax.
Perform massage two times daily taking 20 minutes each time.