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Standard Operating Procedure for the Care and Management of theSkin in Patients with lymphoedema /Chronic Oedema

DOCUMENT CONTROL:Version: 1Ratified by: Clinical Effectiveness Committee

Date ratif ied: 12 April 2012Name of originator/author: Head of Lymphoedema ServiceName of responsiblecommittee/individual:

Clinical Effectiveness Committee

Date issued: 2 May 2012Review date: April 2015Target Audience All Healthcare Professionals


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1. Aim

The aim of the policy is to provide guidance and best practice for ALLhealthcare professionals treating patients who are at risk or have developedskin problems as a result of Lymphoedema/Chronic Oedema.

2. Scope

Patient groups identified at risk of developing Lymphoedema/ChronicOedema:-

Patients following surgery or radiotherapy for cancer

Patients with chronic venous problems Patients that need to use wheelchairs regularly and as a consequence

have chronic swelling of lower limbs Patients with familial / congenital swelling (primary lymphoedema)

Obese/bariatric patients who have leg swelling

All these patients need to maintain the integrity of their skin to:

prevent further progression of dry skin conditions. reduce the risk of trauma reduce the risk of developing cellulitis which scars the lymphatic

system.

3. Link to Overarching Policy.

This Policy links with Tissue Viability Policies for the Trust.

4. Procedure

In order to educate the patient the healthcare professional needs tounderstand the causes of dry skin:

Environment Aging. Medication

Medical problems Radiotherapy Obesity Nutrition Fluid Balance

Infection Cigarette Smoking

Promoting Healthy Skin.

In healthy skin, the balance of water and lipid content keeps the epidermisintact and the skin soft and supple (Linnitt 2007)

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Good skin care is important to maintain and improve the condition of theepidermis and dermis, so that they are well hydrated, supple and intact(Dohery 2009)

Patients should be advised to :-

Wash skin daily in warm water.

Washing with emollient/cream i.e. Aqueous, Hydromol emollient E45wash, Balneum (itchy skin only).(Emollients work by re-establishing the protective surface lipid layer ofthe skin and enhance rehydration. They create a further barrier toprevent further water loss and protect the skin from bacteria Moffatt2006)

Drying this is very important. Vigorous rubbing will irritate the skinand cause epidermal changes. Gently pat skin dry, not forgettingbetween toes and fingers pay attention to creases and skin folds.(Advice should be given about the possibility of the bathroom being aslippery surface due to the oils.)

Moisturise to maintain integrity of skin i.e. bland emollient.

Application of moisturiser:-

1. Always start at the root of the affected limb.

2. Using gentle upward gentle strokes apply a thin layer of creamto the limb

3. Work down the whole length of the limb always strokingupwards (DO NOT rub cream in)

4. Once hand reached gently stroke back of hand, palm thenfingers. For foot stroke top of foot then sole then toesremembering not to apply cream between toes.

5. Starting at root of limb gently stroke down the whole length ofthe limb to smooth any hair follicles and reduce the risk oftrauma/infection.

Patients should be education/information should also include:-

Regular checking of between fingers, toes creases for any signs ofinfection.

Nails trimmed appropriately, encourage if possible file nails to reduce therisk of accidental trauma.

Not to wear tight clothing, jewellery or footwear on the affected limb.

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DO NOT ALLOW:

Venepuncture or blood pressure taking from an arm, the same side asbreast cancer surgery.

Injections in limbs adjacent to cancer surgery

BE EXTRA CAUTIOUS OF:

insect bites accidental injuries i.e. cuts, abrasions adverse temperatures suns rays walking bare foot if leg swelling an issue

Lymphoedema is associated with an altered immune response that canresult in an increased sensitivity to i rritants and allergens (Williams andVenables, 1995).

In view of this creams should be observed wi th care because Creamsare a mixture of ointment and water containing preservatives, whichmay act as sensitises resulting in a contact allergic eczema, (Cameron,1998)

Emollients are available in a variety of presentations. These include: -

Creams - which are oil in water emulsions, which are generally well absorbedinto the skin. Creams are less greasy and more easily applied. Used to treatminor skin conditions i.e. E45, Hydromol cream, aqueous. These work in twodifferent ways. After first applying the cream water is lost from the mixture byboth evaporation and absorption into the skin. This has the effect of coolingthe skin and alleviating itching. Secondly the water loss from the mixture,combined with the mechanical stress of applying the preparation, causes theemulsion to crack. This releases the oil phase whereby oil is released onto thesurface of the skin, sealing it, and preventing any further water evaporationfrom the skins surface. (Courtenay, 1998).

Ointments are greasy preparations, normally anhydrous and insoluble inwater and are more occlusive than creams. Particularly useful in chronic drylesions. i.e. Hydramol ointment, emulsifying ointment. Ointments containhigher oil content and produce a greater sealing effect on the skin, resulting inless water loss (Courteney, 1998).

Lotions these are solutions, suspensions or emulsions. Lotions have acooling effect on the skin and are often preferable to creams or ointments i.e.E45 lotion.

Bath emollients: - washing regularly is essential to keep skin clean, protect it

from infection and remove dead skin cells. Water alone can, paradoxically, dryout the skin, so baths oils need to be added i.e. E45 bath, Diprobath, Oilatum.

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However, it is important to advise of the fact that oil may make the bath veryslippery, so care needs to be taken to ensure safety.

REFERENCES

Cameron, J (1990) Patch testing for leg ulcer patients Nursing Times 86 (25) 14-16

Courtenay, M (1998) Preparation for skin conditions Nursing Times 94(7) 54-55

Doherty, D. (2009) Skin care considerations in chronic oedema. Chronic OedemaApril 2009 S4-12

Linnit.N. (2007) Complex skin changes in chronic oedemas. The Lymphoedema

Supplement April (2007) S10-15

Lymphoedema framework (2006) Best practice Document for the Management ofLymphoedema. MEP Ltd 2006 pg 24

Moffatt, C. (2006) Skin care management for patients with lymphoedema. WoundEssentials 1: 172-4

Peters.J (1999) Eczema Nursing Standard 14 (16) 49-55.

Williams, A and Venables, J (1995) skin care in patients with uncomplicatedLymphoedema. J ournal of Wound Care 5 (5) 223-226.

Wingfield, C. (2009) Chronic Oedema: The Importance of Good Skin Care. WoundEssentials (2009) Vol 4 pg 26-34

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