What Does It Mean When You Are So Edematous That Your Skin Is Weeping

Lower-limb lymphorrhoea poses medical and practical challenges for patients and nurses, but can exist avoided if lower-limb oedema is treated early. This commodity comes with a self-cess enabling you to exam your knowledge after reading information technology

Abstract

The direction of lower-limb lymphovenous disease and lymphorrhoea ('leaky legs') is challenging. The root cause of the disease must be addressed and the chance of infection minimised while symptoms are treated with pinch, dressings, topical agents and barrier products. Lymphorrhoea causes meaning medical and practical issues for patients and nurses, just tin be avoided if lower-limb oedema is treated early. This article describes the pathophysiology, direction strategies, and clinical and practical bug associated with the status; it updates an article published in 2003.

Citation: Anderson I (2016) 'Leaky legs': strategies for the handling and management of lower-limb lymphorrhoea. Nursing Times; 113: 1, 50-53.

Author: Irene Anderson is national teaching fellow and principal lecturer (tissue viability), and reader in learning and teaching in healthcare practice at the School of Health and Social Piece of work, University of Hertfordshire.

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 Introduction

The management of lymphorrhoea (grossly oedematous legs) poses major challenges because the condition is often accompanied by the leakage of considerable volumes of fluid – indeed the condition is usually known equally 'leaky legs' (Lymphoedema Framework, 2006). This article describes the pathophysiology of lymphovenous disease, strategies to assistance forestall or treat complications, and clinical and practical issues for patients and health professionals; it updates a previous Nursing Times article (Anderson, 2003a). Lymphorrhoea can affect whatsoever limb (Renshaw, 2007), but this commodity focuses on the leg.

Lower-limb oedema

Lower-limb oedema first manifests as swelling at the ankle; if this is non controlled, swelling quickly extends to the foot and leg. Swelling is initially soft and 'pitting' merely, as the trouble becomes chronic, the tissues harden and it becomes increasingly difficult to reduce the oedema. In the early stages, just sleeping and sitting with the ankles elevated in a higher place hip level and applying mild compression will opposite the oedema, but if its cause is non addressed, these measures will not foreclose the status from becoming chronic. The prevalence of diagnosed chronic oedema is around four per 1,000 of the Britain population, but this figure is widely idea to be an underestimate (Todd, 2014).

Lymphovenous disease

Oedema occurs when capillary pressure exceeds the pressure level of fluid in the tissues, causing fluid to leak from the circulatory system and accumulate in the tissues (Lawrance, 2009). The lymphatic organisation is responsible for fluid drainage, only if filtration from the capillaries (Fig ane) and venules exceeds drainage capacity for besides long, limb swelling occurs (Mortimer and Rockson, 2014). The blood circulation and lymphatic systems vest to a network (Fig 2), so extra congestion and force per unit area in the circulatory organization leads to actress book and pressure level in the lymphatic system, increasing the leakage of fluid into tissues.

Lymphoedema occurs when a problem in the lymphatic drainage organization causes fluid to accrue in the tissues; it can be primary (whereby a genetic trigger causes the arrangement to fail) or secondary (whereby trauma causes the failure). Sometimes the drainage vessels tin can exist damaged by infection such as cellulitis (Lymphoedema Support Network, 2015).

Chronic oedema is caused by problems with venous render. This unremarkably happens because the valves in the veins fail to shut properly, resulting in a backflow of venous blood leading to higher than normal pressures in the veins (venous hypertension). The boosted blood causes the venous walls to stretch and plasma to leak into the tissues; the veins are unable to drain the fluid back from the tissues because they are already congested.

Lower-limb oedema tends to be a mix of all the higher up, and is known every bit lymphovenous disease (Rockson, 2010).

Lymphorrhoea

Understanding of the fluid drainage machinery has evolved in recent years. There is now more than emphasis on the function of the lymphatic system to drain interstitial fluid (fluid in the tissues), rather than on venules in the circulatory system reabsorbing interstitial fluid (Jacob and Chappell, 2013). At that place is nonetheless much that we exercise not sympathise (Levick and Michel, 2010), merely we know that improving lymphatic drainage every bit much as possible is a priority.

As lymphovenous affliction progresses, specially if it is not well managed, legs can become grossly oedematous; swelling causes the skin to stretch and small blisters announced. Fluid then leaks out and has nowhere to go because both drainage systems (circulatory and lymphatic) are too congested (Elwell and Craven, 2015). The leg appears shiny with moisture or, more commonly, fluid is seen running downwardly the leg (Elwell and Craven, 2015).

The fluid leaking from the leg is transudate (fluid that has passed through a membrane); it has loftier fluidity and low protein content (as opposed to wound exudate).

Implications for patients

Patients with lymphorrhoea study intense hurting (Lymphoedema Framework, 2006) due to swelling, as well every bit irritation, maceration (whitening and 'bogginess') and excoriation (redness and rawness) of the skin due to wetness. Eventually the skin breaks down into at least one ulcerated expanse, and the chance of infection increases (Quéré and Sneddon, 2012). Patients besides experience high levels of discomfort, embarrassment and inconvenience, not to mention expenses. They have to live with a leg that is extremely swollen and heavier than normal – imagine trying to walk up or down stairs with a limb and then heavy you can barely lift it, or to walk without existence able to flex your ankles because they are so swollen. Patients will as well be constantly wet and have permanently moisture footwear, clothes and bedding (Morgan et al, 2011).

Adventure of infection

If fluid accumulates in the tissues and is not drained, there is a run a risk of infection. The lymphatic system is a key element of the immune system, and then if it is compromised, the gamble of infection from seemingly modest factors, such every bit scratches or insect bites, increases and can rapidly become serious (Mortimer and Rockson, 2014). In lymphorrhoea, the pare is broken and very moisture, which increases the run a risk of infection; the risk of sepsis is besides loftier (Elwell and Craven, 2015). Acute infection itself results in tissue oedema, and volition therefore add to the existing oedema.

Cellulitis is a potentially life-threatening subdermal and subcutaneous tissue infection commonly caused by Streptococcus pyogenes (two-thirds of cases) and Staphylococcus aureus. It is treated with oral antibiotics in milder cases, or intravenous antibiotics warranting infirmary access in more severe cases (Opoku, 2015). Erysipelas is an infection affecting the superficial layers of the skin and is frequently caused past group A beta-haemolytic streptococci. Cellulitis and erysipelas, which are often indistinguishable but almost e'er unilateral (Opoku, 2015), occur in patients with lymphovenous affliction and lymphorrhoea.

Treatment strategies

Treatment of lymphovenous disease hinges on the utilise of compression, leg peak and exercises that increment motility in the talocrural joint and dogie muscles (O'Meara et al, 2012). Oedema must exist managed to reduce congestion and swelling but treating infection, if nowadays, is a priority. In the presence of infection, the skin will exist particularly vulnerable to breakdown and the patient may feel intense pain, and so pinch and limb management will need to be conducted more frequently, and compression tin be applied at lower pressures than normal. Once the infection is under control, management can focus on reducing swelling and leakage.

Managing lymphorrhoea can exist extremely difficult. At that place are many reports of patients resorting to placing their leg in plastic bags or using nappies, germ-free towels or incontinence pads in an attempt to manage the book of fluid. Nurses may use multiple dressings, which volition need to exist changed oftentimes; this is both plush and time-consuming.

Pinch

Pinch comes in many shapes and forms, including bandages, hosiery, wrap systems and pneumatic compression. The cardinal is to select a technique that applies pressure level firm enough to annul the tissue pressure level, thereby squeezing the veins and valves to cease the backwards flow of venous blood. This will reduce force per unit area in the veins and lymphatic vessels, allowing more fluid to flow back into the drainage system (O'Meara et al, 2012).

Sustained compression volition reduce swelling; the right compression volition effect in a fairly rapid reduction of oedema, so it must be oftentimes readjusted to ensure a tight enough squeeze on the leg. When bandages are used, they must be reapplied as presently as they experience loose. When large volumes of fluid are leaking it may be necessary to apply more sub-bandage padding than usual, merely this can be reduced once the leakage diminishes (Renshaw, 2007). Renshaw (2007) suggests that brusque-stretch bandaging can be more comfy than medium- or long-stretch, as it applies a low pressure when the patient is resting.

Hosiery is not normally used when the leg is leaking, because applying and removing it when the peel is so frail increases the risk of trauma, while abiding contact with moisture material can also impairment the peel. Nonetheless, once lymphorrhoea is under control, hosiery can help reduce swelling (Lymphoedema Framework, 2006). If compression hosiery is to be used, the leg will need to be re-measured to ensure the correct size is used.

The newer wrap systems tin can be adjusted in situ, but if in that location has been a significant reduction in limb size, they will need to be re-measured and cutting. Patients may be able to make adjustments themselves, but re-measuring and cutting or replacing the wrap system must be done by a health professional.

Whatever system is chosen, it must be acceptable and tolerable for the patient. In the astute handling stage, materials that have become wet will need to be often inverse – cost-effective materials should, therefore, be used.

Dressings

Dressing technology has steadily improved in the by decade. Mod materials such as alginate, hydrofibres and absorbent granules increment the chapters of dressings to absorb fluid. While most dressings are absorbent to some degree, some are particularly absorptive and are often chosen 'super absorbents'. Other innovations include gelling fibres – complex fibre structures and/or silicone – and products that control the direction of fluid flow to protect the skin (Cowan, 2016).

Despite these advances, many challenges remain. The quantity of fluid can apace exceed dressing capacity, while information technology tin be difficult to observe dressings that are large enough if the whole leg is leaking. Every bit dressings are absorbent, they accumulate a lot of fluid, becoming heavy and prone to slippage; this may pull and tear skin that is already vulnerable. Some dressings are absorbent considering they are bulky, so they make an already-swollen limb even bigger.

One of the principles of compression is that higher pressures are applied on smaller circumferences so that a larger circumference results in lower sub-bandage pressure (Thomas, 2014); this means that, when there is a lot of extra padding adding to limb circumference, at that place is a chance that non enough force per unit area is existence exerted on the leg. When super-absorbent dressings are swollen with fluid, they may exert boosted localised pressure, leading to changes in the pressure contour and mayhap to force per unit area damage.

Nurses should refer to local dressing formularies and discuss any challenges with a tissue viability nurse or other professional with responsibility for the formulary. Whichever dressing is selected, it should be a comfortable fit, and should non cause discomfort when it has reached its absorbency capacity, or agree exudate against periwound skin.

Topical agents

Some astringent and mildly antiseptic substances are used on very wet peel, but their efficacy is debated. Treating very wet skin with topical substances is a claiming; decisions must sometimes be based on clinical feel rather than bear witness, every bit there is trivial evidence on the subject. The primal objective is to manage the underlying trouble and not utilize topical agents for prolonged periods. For example, potassium permanganate solutions tin can help in acute episodes of lymphorrhoea simply should non be used for more than x days (Elwell and Craven, 2015). They must be used and disposed of according to the manufacturer'south instructions, and so pare, nails, vesture and household items are protected from staining (Nazarko, 2013). Although the evidence base is weak, potassium permanganate is reported to be useful in wet, weeping legs. Its use should be discontinued when the leg dries (Anderson, 2003b).

Antimicrobial agents such as silver, iodine and honey can be applied, especially in the presence of wounds, when at that place is an infection or when the gamble of infection is high. Current practise is not to utilise them for more than two weeks at a time, then their employ must be judiciously timed (Beldon, 2014). Dressings containing antimicrobials should exist selected to provide maximum absorbency and condolement.

Barrier products

In lymphorrhoea, pare integrity is compromised not only past the swelling and fluid, only also the enzymes independent in the fluid, which tin destroy healthy tissue (Adderley, 2010). The peel therefore needs to exist protected with products that isolate information technology from the fluid. So-called barrier products come up in various forms, including creams, sprays and sticks. Silicone plays a key office: it forms a blanket that the fluid sits on, rather than resting straight on the pare. Manufacturers' instructions must be followed carefully so the quantity of product applied is sufficient to create a barrier simply does not hinder normal vapour loss through the peel (Draelos, 2012).

Diuretics

Both Al-Niaimi and Cox (2009) and Mortimer and Levick (2004) state that diuretics are not generally helpful in the management of lymphovenous disease. Keast et al (2015) add that there is no, or only minimal, response to diuretics in chronic oedema acquired by lymphovenous disease. Withal, lower-limb swelling and fluid leakage tin have various causes, including renal disease, cancer, drug therapy and heart failure (Keeley, 2008), and diuretics may help reduce lower-limb oedema acquired by heart failure (Khatib, 2011). If heart failure is the underlying problem and across advisable medical direction, pinch therapy may be contraindicated; it should but exist used under specialist supervision until arterial catamenia to the extremities is determined (Top et al, 2009).

Practical issues

In their written report of complex lymphoedema, Morgan et al (2011) highlighted a link between obesity and lymphoedema and the increased incidence of lymphorrhoea. They also explored bug around patients' beliefs and motivation to participate in their treatment plans. This study focused on lymphoedema, but the management of chronic oedema involves many of the aforementioned issues, especially in patients with heavy and already-vulnerable limbs.

Specialist equipment such equally therapy couches may be required to manage heavy patients. Sometimes two health professionals are needed to wash the patient, apply topical treatments and/or barrier products, bandage limbs and care for lymphorrhoea (Morgan et al, 2011). Nurses must be prepared to deliver 'intensive care' for the leg in the early on stages, which will assistance avoid complications and ultimately be less costly and risky than having to manage wet and swollen legs over long periods.

From a nursing perspective, patient management consists mostly of pain control (Lymphoedema Framework, 2006) and local management of the fluid. If diuretics are used, patients volition need additional support to manage increased urine output, both in terms of actress visits to the toilet and peel integrity; this may make some patients reluctant to have diuretics. Practicalities and implications must be discussed with patients when treatment is existence planned; recording the progress of therapy tin be useful to motivate them (Box 1).

Box 1. Documenting progress

Documenting assessments, treatments and outcomes is a requirement of good professional person do (Nursing and Midwifery Quango, 2015), only it is also part of good management and can be motivating for patients and nurses akin.

Regularly measuring limb circumference at the ankle and calf allows nurses to evaluate the result of handling. Sketches or, better still, good-quality photographs, will also help approximate progress and discover any deterioration or breakdown of the skin, thereby enabling complications to exist treated early. Measurements and sketches/photographs too support good communication between wellness professionals, such every bit when a general practice nurse needs specialist communication.

When taking pictures of patients, nurses must follow local policies regarding consent and information management (Plant of Medical Illustrators, 2012).

Conclusion

Managing oedematous and leaking legs is a clinical challenge for health professionals and for patients. Nurses need to recognise what is happening and seek to accost the root cause, while using absorbent materials and, where possible, compression therapy to reduce the accumulation of fluid. Cellulitis tin exist prevented by good oedema and skin direction, just if it does occur it must exist treated equally a priority. An 'intensive treatment' approach to lower-limb oedema in the early stages will avoid many complications, including lymphorrhoea, that ascend if the condition is not well managed. Box ii lists online resources that tin can be used to back up direction plans.

Key points

• Grossly oedematous and leaking legs nowadays direction challenges for both nurses and patients
• Patients with lymphorrhoea feel enormous medical and practical issues
• The nurse's function is to address the cause of lymphovenous affliction while reducing fluid accumulation, leg swelling and risk of infection
• If cellulitis occurs it must exist treated as a priority
• Proactive management of lower-limb oedema equally presently as it presents helps to avoid complications such every bit lymphorrhoea

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Source: https://www.nursingtimes.net/clinical-archive/tissue-viability/leaky-legs-strategies-for-the-treatment-and-management-of-lower-limb-lymphorrhoea-19-12-2016/

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