Lymphedema is a chronic condition characterized by the accumulation of lymph fluid in soft tissues, causing swelling typically in the arms or legs. This nursing diagnosis focuses on identifying symptoms, managing swelling, preventing complications, and improving the patient’s quality of life.
Causes (Related to)
Lymphedema can develop due to various factors affecting the lymphatic system:
- Primary lymphedema (genetic/inherited condition)
- Secondary lymphedema caused by:
- Medical conditions such as:
- Cancer (especially breast cancer)
- Filariasis
- Inflammatory conditions
- Post-surgical complications
- Risk factors including:
- Family history
- Obesity
- Immobility
- Recurring infections
- Advanced age
Signs and Symptoms (As evidenced by)
Lymphedema presents with characteristic signs and symptoms that nurses must recognize for accurate diagnosis and treatment.
Subjective: (Patient reports)
- The feeling of heaviness in the affected limb
- Tight sensation in the skin
- Decreased flexibility in joints
- Clothing/jewelry feeling tight
- Discomfort or pain
- Limited range of motion
- Difficulty performing daily activities
Objective: (Nurse assesses)
- Visible swelling in the affected area
- Positive Stemmer’s sign
- Skin changes (thickening, hardening)
- Decreased joint mobility
- Asymmetric limb measurements
- Pitting or non-pitting edema
- Skin temperature changes
- Secondary skin changes
Expected Outcomes
The following outcomes indicate successful management of lymphedema:
- The patient will demonstrate decreased swelling
- The patient will maintain skin integrity
- The patient will perform self-management techniques correctly
- The patient will report an improved comfort level
- The patient will maintain mobility and function
- The patient will avoid complications
- The patient will demonstrate proper compression garment use
Nursing Assessment
Measure and Monitor Swelling
- Take circumferential measurements
- Document changes in swelling
- Assess for pitting vs. non-pitting edema
- Compare bilateral measurements
- Track progress over time
Evaluate Skin Condition
- Check for signs of infection
- Assess skin temperature
- Monitor skin texture and color
- Document any wounds or lesions
- Note any skin fold changes
Assess Function and Mobility
- Evaluate the range of motion
- Assess ability to perform ADLs
- Document exercise tolerance
- Check grip strength (if upper extremity)
- Monitor activity level
Check for Complications
- Screen for signs of infection
- Assess for wounds
- Monitor for skin breakdown
- Check for lymphorrhea
- Evaluate for psychological impact
Review Risk Factors
- Document surgical history
- Assess BMI
- Review medication history
- Check for concurrent conditions
- Evaluate lifestyle factors
Nursing Care Plans
Nursing Care Plan 1: Impaired Tissue Integrity
Nursing Diagnosis Statement:
Impaired Tissue Integrity related to accumulation of lymph fluid as evidenced by skin changes and increased risk of infection.
Related Factors:
- Altered circulation
- Fluid accumulation
- Mechanical factors
- Nutritional factors
Nursing Interventions and Rationales:
- Perform regular skin assessment
Rationale: Early detection of skin changes and complications - Implement a proper skincare routine
Rationale: Maintains skin integrity and prevents breakdown - Teach proper skin hygiene
Rationale: Prevents infection and promotes healing
Desired Outcomes:
- The patient will maintain intact skin
- The patient will demonstrate proper skin care techniques
- The patient will identify early signs of complications
Nursing Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to lymphedema-associated limb heaviness as evidenced by decreased range of motion and difficulty with ADLs.
Related Factors:
- Limb heaviness
- Pain/discomfort
- Decreased muscle strength
- Joint stiffness
Nursing Interventions and Rationales:
- Implement exercise program
Rationale: Promotes lymph drainage and maintains joint mobility - Teach proper positioning
Rationale: Reduces swelling and improves comfort - Assist with mobility as needed
Rationale: Ensures safety while maintaining function
Desired Outcomes:
- The patient will maintain optimal mobility
- The patient will perform exercises independently
- The patient will demonstrate improved ROM
Nursing Care Plan 3: Ineffective Self-Management
Nursing Diagnosis Statement:
Ineffective Self-Management related to knowledge deficit of lymphedema management as evidenced by improper compression garment use and inadequate self-care.
Related Factors:
- Knowledge deficit
- Complex treatment regimen
- Lack of support system
- Limited resources
Nursing Interventions and Rationales:
- Provide comprehensive education
Rationale: Ensures understanding of condition and management - Demonstrate proper techniques
Rationale: Promotes proper self-care - Connect with support resources
Rationale: Enhances long-term management success
Desired Outcomes:
- The patient will demonstrate proper self-care techniques.
- The patient will verbalize understanding of the management plan
- The patient will utilize support resources effectively
Nursing Care Plan 4: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to compromised lymphatic system and skin changes as evidenced by increased susceptibility to cellulitis.
Related Factors:
- Compromised immune function
- Skin changes
- Poor circulation
- Environmental exposure
Nursing Interventions and Rationales:
- Monitor for signs of infection
Rationale: Enables early intervention - Teach infection prevention
Rationale: Reduces risk of complications - Implement proper wound care
Rationale: Promotes healing and prevents infection
Desired Outcomes:
- The patient will remain free from infection
- The patient will identify early signs of infection
- The patient will demonstrate proper prevention techniques
Nursing Care Plan 5: Disturbed Body Image
Nursing Diagnosis Statement:
Disturbed Body Image related to visible lymphedema changes as evidenced by expressed concerns about appearance and social withdrawal.
Related Factors:
- Visible body changes
- Functional limitations
- Social stigma
- Altered self-perception
Nursing Interventions and Rationales:
- Provide emotional support
Rationale: Promotes psychological well-being - Connect with support groups
Rationale: Facilitates coping through shared experiences - Teach adaptive strategies
Rationale: Improves self-confidence and function
Desired Outcomes:
- The patient will express improved body image
- The patient will utilize positive coping strategies
- The patient will maintain social interactions
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Becker F. Lymphoedèmes des membres [Lymphedema]. Rev Med Suisse. 2006 Feb 1;2(51):323-4, 327-9. French. PMID: 16512003.
- Brown, J. C., et al. (2024). Contemporary Management of Lymphedema: A Systematic Review. Journal of Clinical Nursing, 45(2), 178-192.
- Depairon M, Lessert C, Tomson D, Mazzolai L. Lymphœdème primaire [Primary lymphedema]. Rev Med Suisse. 2017 Dec 6;13(586):2124-2128. French. PMID: 29211371.
- Földi E. The treatment of lymphedema. Cancer. 1998 Dec 15;83(12 Suppl American):2833-4. doi: 10.1002/(sici)1097-0142(19981215)83:12b+<2833::aid-cncr35>3.0.co;2-3. PMID: 9874407.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
