Lymphedema Nursing Diagnosis and Nursing Care Plan

Lymphedema Nursing Care Plans Diagnosis and Interventions

Lymphedema NCLEX Review and Nursing Care Plans

Lymphedema (LE) is a medical condition characterized by apparent swelling of the extremities due to excessive lymph drainage in the subcutaneous tissue.

LE is divided into two types – primary and secondary lymphedema, each of which can be caused by several etiological factors, including trauma, congenital defects, lymphatic vessel abnormalities, interruption in the lymphatic circulation, injury, or specific conditions.

Signs and Symptoms of Lymphedema

Swelling in the extremities
Impaired mobility
Recurring infections
Hardening of skin (fibrosis)
A heavy and constricted feeling
Pain
Skin creases
Reduced flexibility
Reddening of skin

Anatomy of the Lymphatic System

Lymph. A clear and protein-rich fluid formed from transudation
Lymph vessels. This network of microvessels (capillaries) and tubes collects interstitial fluid and transports it to and away from lymph nodes, where it is filtered.
Lymph nodes. These glands are distributed throughout the body and function by filtering pathogens, cancer cells, and other foreign particles from the lymph. It is also involved in the immune system and inflammatory response and stores lymphocytes.
Collecting ducts. This is the area where lymph is emptied. The right lymphatic duct drains the lymph in the upper quadrant, whereas the collecting duct drains the lower body (e.g., lower extremities, abdomen). These ducts prevent excess fluid accumulation in tissue spaces and restore lymph to the blood circulation in order to maintain normal blood pressure and blood volume.

Other organs containing lymphatic tissues are:

Thymus. This lymphoid organ is associated with cell-mediated immunity since it facilitates T-cell maturation.
Spleen. The largest organ in the lymphatic system; responsible for blood filtration and leukocyte production.
Tonsils. Considered to be the first line of defense in the lymphatic system; responsible for releasing antibodies and lymphocytes against foreign bodies that have been ingested.
Appendix. A lymphoid tissue that is associated with maintaining gut microbiome or flora and helps remove waste matter in the digestive tract.
Peyer’s patches. Monitors and provides responses to pathogen invasion in the intestine, particularly the ileum.

Stages of Lymphedema Formation

Stage 0. This stage is characterized by the absence of tissue edema. The condition may be in its preclinical stage, and symptoms may not yet be present. The limbs feel heavy upon elevation. May persist for months or even years before symptoms become obvious.
Stage I (Reversible). There is an obvious accumulation of fluid and edema within the interstitium, which can be alleviated by elevating the involved extremity. Pitting edema of the tissue can cause fluids to be easily squeezed out, leaving a dent in the swollen skin upon applied pressure.
Stage II (Irreversible). There is permanent swelling due to chronic inflammation. The release of proteases and extracellular matrix proteins are affected by pathological states, which could lead to the enrichment of proteins, including collagen in the lymph. The concentration of proteins (e.g., laminin, mucins, fibronectins) in the interstitial fluid can lead to diffusion and scarring. Chronic activation of the inflammatory response can result in the proliferation of smooth muscle cells and connective tissue, leading to occlusion and fibrosis. In the event of an occlusion, the lack of lymphatic support might result in abnormal or elevated hydrostatic pressure, causing lymph stasis. This stage is also marked by swelling that is not alleviated by elevating the affected limb. Edema without pitting is caused by an increase in skin density.
Stage III (Elephantiasis). This is the most severe stage, and it is typically associated with filarial infection. It is characterized by the persistent breakdown of lymph vessels and lymph nodes, leaving patients susceptible to infection. The chronicity of edema causes skin alterations that are typically grotesque in appearance, with warty skin proliferation, thickness, stiffness, discoloration, and papilloma leakage. The limbs are doubled in size, limiting mobility and increasing the risk of tinea pedis.

Risk Factors to Lymphedema

Family history
Age
Presence of infections
Obesity

Causes of Lymphedema

Causes of Primary Lymphedema (PL)

The cause of swelling can be attributed to genetic or inborn factors, intrinsic, abnormal lymphatic vessel architecture, and dysfunction. The condition resulting from an abnormal lymphatic architecture is frequently inherited and is therefore regarded as a risk factor since it increases LE susceptibility.

Familial lymphedema (LE shown in more than one member of the family) is mandated by various modes of inheritance, primarily autosomal dominant, recessive, and X-linked. However, a new dominant event can result from a genetic disorder, as in the case of sporadic PL, which has a genetic basis but no family history. A disease-causing mutation may also be inherited but not clinically expressed (e.g., non-penetrance). PL can also be attributed to several pathological states, including dysplasia and abnormal vascular abnormalities. The following are other etiologies contributing to PL:

Klippel-Trenaunay-Weber syndrome

Turner syndrome. Dysmorphic characteristics include a webbed neck, nail dysplasia, a high-arched palate, small stature, a short fourth metacarpal, congenital LE of the hands and feet, Madelung deformity, and scoliosis. This syndrome is caused by the presence of two distinctive phenotypes: a normal X and the lack of the second chromosome or partial deletion. Congenital lymphedema should be investigated in women with TS if their hands and feet are impacted.

Milroy disease. LE may be present at birth and usually presents symptoms of swelling in the limbs and feet, hydrocele (fluid buildup in the scrotum), and skin changes. It is inherited in an autosomal dominant pattern, and mutations in FLT4 genes are implicated. Milroy disease is also associated with intestinal lymphangiectasia (diffusion of lymph fluid into the gastrointestinal tract) and cholestasis, which can result in hypoproteinemia, lymphocytopenia, edema, etc.

Meige disease (Familial lymphedema praecox). Disease inherited in an autosomal dominant pattern that predominantly affects females. This is attributed to mutations in the transcription factor gene (FOXC2), which is related to distichiasis, cleft palate, and edema in the extremities (and rarely the face). Patients with FOXC2 expression in the venous valves (VVs) also experience venous insufficiency and valvular incompetence. This could potentially prevent lymphatic backflow.

Causes of of Secondary Lymphedema (SL)

Filariasis. This condition involves infection of roundworms or lymph-dwelling parasites (Wuchereria bancrofti, Brugia timori, and Brugia malayi) through vector transmission. The larvae proliferate and infiltrate the lymphatic channel, leading to occlusion. Upon death, it damages and triggers the inflammatory response. Besides the resulting inflammation, it often progresses and causes limbs to swell.
Surgery. One of the most common causes of LE is iatrogenic injury due to radiation therapy for the treatment of malignancies (e.g., breast, prostate, cervical cancer, and melanoma). Surgical procedures such as the removal of tumors and lymph node dissection may lead to scar formation and swelling; however, the symptoms may be delayed for three months or even a year; hence, transitory swelling may resolve but progressively resurface in a few patients.
Trauma. Injury and trauma can cause damage to the lymphatic nodules and vasculature. It reduces transport capacity and disrupts the lymphatic flow. For instance, a bone fracture can cause enlargement of lymphatics and lymph nodes since it triggers the inflammatory response and infectious process. Other types of trauma include pelvic fracture, brachial plexus injury, accidents, burns, thermal injury, falls, and crush injury.
Tumor. Lymphatic flow interruption can be tumor-mediated. The tumor can metastasize and obstruct regional lymph nodes and vessels.
Therapeutic or diagnostic interventions that culminate in iatrogenic injury. Radiation therapy can contribute to tissue fibrosis and may limit the availability of auxiliary channels, resulting in a reduction in lymphatic circulation. The pharmacologic or therapeutic treatment may also reduce the size of lymph nodes and inhibit the repair of lymphatic vessels, hence impairing the lymphatic system and hindering future responses to trauma or infection. Inappropriate or prolonged use of a tourniquet on a limb may potentially result in direct tissue damage.
Infection. Lymphangitis and other recurrent infections contribute to fibrosis and scarring. The lymphatic system may be insufficient in immunocompromised patients due to systemic insufficiency, and the decrease in functional responsiveness may result in LE. Infections including Verrucosis and lymphangiectasia engorge lymphatic channels. Interdigital entry lesions in the legs can result in bacterial infection as a secondary disease or complication of LE. Another response to external irritants is inflammation, which increases the permeability of the vasculature and permits the extravasation of lymphatic fluid, resulting in swelling.

Complications of Lymphedema

Infections (e.g., cellulitis, lymphadenitis)
Poor wound healing
Skin ulcers
Psychological implications of disfigurement
Repeated hospitalizations
Tumors
Fibrosis

Diagnosis of Lymphedema

Medical history. A thorough understanding of the patient’s medical history is essential in making a proper diagnosis since LE and edema might be mistaken for one another. Established familial LE implies PL, whereas SL is frequently the result of trauma, blockage, or injury. Similarly, edema is caused by sodium retention, increased hydrostatic pressure, decreased venous return, hepatic dysfunction, renal failure, and other factors.
Lymphoscintigraphy. Reveals distinctive changes and impaired lymphatic transport due to lack of uptake of colloid or tracer in the lymph nodes and groin area. Typically, a stinging sensation is felt when the colloid is injected into the foot or hand web space. Five minutes of limb workouts on a foot ergometer or squeeze ball are given, followed by one-minute exercises every five minutes for an hour. Images are captured, and the status of lymph node uptake and dermal backflow are recorded. It is considered abnormal when there is no tracer or radioisotope clearance from the injection site, poor visibility of dermal backflow, and absence of lymph node uptake.
Computed tomography (CT scan). This diagnostic test identifies the presence of a mass or tumor in secondary LE. It also allows visualization of the lymphatic network and fluid buildup in tissue spaces.
Lymphangiography. This test is often regarded as the gold standard for diagnosing LE. In order to visualize the lymphatic system, a contrast agent is injected subcutaneously into the dorsal region of the hand or foot. As part of the imaging protocol, the patient is assisted into a supine position with feet flattened on the table. After staining the lymphatics, epinephrine and lidocaine infiltration occurs, and an incision is made using a scalpel. The lymphatics are dissected, and a 30-gauge needle (lymphangiogram needle) is placed into the vessel to continuously infuse lipiodol.
Circumferential measurements. Circumferential discrepancies between two limbs using cloth tape are evaluated and compared.

Treatment of Lymphedema

Manual lymphatic drainage (MLD). It involves intensive massage performed by trained healthcare practitioners, wherein the accumulated fluid is massaged and moved into spaces away from the limb.
Compression. Drains lymphatic fluid and increases lymphatic flow due to the increased interstitial hydrostatic pressure. The use of graduated or high-grade compression stockings and bandaging may aid in the maintenance of shape and drainage in patients who have achieved therapeutic gains. Typically, this is given following a massage of the affected limb. It is recommended that stockings be replaced every four to six months as their compressive effect diminishes. The selection of elastic compression devices is based on the present phase of LE. Stage I is characterized by 20 mm mm Hg pressure (arms; class 1) and 30-40 mm Hg pressure (legs); stage 2 is characterized by 40 mm Hg pressure; stage 3 is custom-made to allow for better standardization to control edema.
Medications. Non-steroidal anti-inflammatory drugs (NSAIDs) may help reduce swelling and provide pain relief.
Surgery. This intervention often has a limited function in patients since it can be a risk factor for developing lymphedema. It can predispose patients to infection and induce lymphatic destruction, damage to lymph collectors, and lymph node enlargement. In severe cases, debulking surgery may be required to restore cosmetic appearance, remove extra tissue, reduce weight, and preserve urinary and sexual function.
Decongestive lymphatic therapy (DLT). This therapy involves the combination of exercises, use of compression bandages, specialized massage techniques (e.g., manual lymphatic drainage or MLD), and good skin care to treat lymphedema.
Non-surgical management strategies for lymphedema. These may include:
- Limb elevation. The legs are lifted 45 degrees above the level of the heart using a sling or foam wedge. It is recommended that outpatients lift their legs for 20 minutes twice or three times per day.
- Bed rest. Temporarily reduces edema and fatigue, but extended bed rest or immobilization can exacerbate lower limb edema.
- Weight control

Exercises for Lymphedema

Exercises are the cornerstone of minimizing the risk of LE, with an emphasis on increasing flexibility, mobility, and strength. The following are examples of exercises that can be performed at home:

Neck exercises
- The head is tilted to one side for three seconds before returning to the center and repeating on the opposite side.
- The chin is brought to the chest for two seconds before the head is progressively brought back up.
Hand exercises. Squeeze the ball while seated comfortably, keeping good posture and shoulders relaxed before gently pressing or flexing
Arm exercises. Touch knees with hands while comfortably seated. Subsequently, touch shoulders and knees without pain.
Marching
Hip rotations
Ankle and knee raises

Nursing Diagnosis for Lymphedema

Lymphedema Nursing Care Plan 1

Acute Pain

Nursing diagnosis: Acute pain related to inflammation and swelling of the limbs or arms, secondary to lymphedema, as evidenced by verbalized pain, tenderness, and signs of sensitivity

Desired Outcome: The patient will have diminished pain perception as evidenced by a low pain score and absence of grimacing after the intervention.

Lymphedema Nursing Interventions	Rationale
Assess the affected limb for pain and have the patient self-report severity on a scale from 0 (no pain) to 10 (extreme pain). Observe nonverbal cues if necessary.	If a patient can adequately describe their pain, the nurse is better able to determine what treatments are required to reduce or eliminate their pain. This evaluation also offers information on the progression of pain and aids in determining whether substantial analgesia is required.
During acute stages, ensure appropriate bed rest and assist with limb elevation.	Reduces painful engorgement and the likelihood of lymph drainage
Offer and apply a warm and moist pack.	Continuous moist heat may be beneficial for alleviating pain or discomfort. Additionally, it increases vasodilation and blood supply to the affected area.
Encourage the patient to report their pain to the healthcare provider before the pain intensifies and offer pain relief options (e.g., medications, warm blankets)	Offering the patient analgesics and other pain-relieving measures can help alleviate the patient’s pain.
Inform patients and significant others about alternate pain treatment choices, such as guided imagery, cutaneous stimulation, heat and cold applications (e.g., moist compresses, ice massage), range of motion exercises, back rubs, biofeedback, and auditory distraction.	Hot and cold applications may relieve muscle tension and tenderness. Range of motion exercises relieves joint stiffness and allows lymphatic drainage. The TENS device (transcutaneous electrical nerve stimulation) may be beneficial when used in conjunction with pharmaceutical treatment.
Suggest the use of compression garments, devices, and elastic bandages. Inform the patient about its purpose, significance, and the necessity of correct fitting.	Compression garments provide sufficient compression to drain lymphatic fluid and minimize edema. However, improper use and ill-fitting compression garments or devices can create focal swelling and intensify the pain.

Lymphedema Nursing Care Plan 2

Risk for Impaired Physical Mobility

Nursing Diagnosis: Risk for Impaired Physical Mobility related to excessive fluid buildup in the limb or arm, secondary to lymphedema.

Desired Outcome: The patient will take precautions to prevent injury and will engage in physical activity within his or her capabilities.

Lymphedema Nursing Interventions	Rationale
Evaluate the patient’s physical mobility prior to surgery.	The evaluation of preoperative mobility provides baseline comparisons and accurate measurements of postoperative mobility issues.
Evaluate the capacity to carry out activities of daily living (ADLs):	Assesses the patient’s fundamental abilities to perform and engage in daily activities. This intervention also determines whether assistance is required and whether activities must be modified. For instance, patients with bilateral edema may have restrictions in mobility and flexibility, as well as discomfort in the extremities.
Check and report muscle strength, coordination, and mass.	This assessment assists in determining the level of mobility and muscular control. An increase in arm and leg volume may exacerbate the feeling of heaviness and constriction, hence reducing movement.
Implement restrictions against movement and ambulation as indicated.	Patients who have undergone lymph node dissection and radiation therapy are limited from frequent mobility to avoid surgical repair.
Instruct the patient in the proper usage of compression garments or devices and ensure that they are properly fitted.	These interventions have an anti-edematous effect by decreasing lymphatic preload and increasing circulation in lymphatic vessels. In addition, it distributes pressure, reduces lower extremity edema, and promotes good standing alignment. However, a device that is not properly fitted can cause pain and restrict motion, as opposed to leaving mobility unrestricted.

Lymphedema Nursing Care Plan 3

Risk For Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity related to immobilization, secondary to lymphedema

Desired Outcome: The patient will maintain skin integrity by expediently improving wound condition, preventing infection, and reporting any observable skin changes.

Lymphedema Nursing Interventions	Rationale
Observe the following features of the skin’s surface: color, texture, elasticity, and temperature	For edematous patients, the skin typically indicates the risk of infection and identifies reversible or irreversible damage (fibrosis). The ongoing assessment also helps monitor the response to treatment and identifies the possible risk of skin breakdown or loss of integrity.
Monitor the patient’s skin status for local spread of systemic infection (e.g., erythema, purulent drainage, local warmth), and note systemic indicators of infection.	The clinical presentation of a nonsystemic infection may signal the presence of diseases such as lymphangitis and erysipelas, which either results in lymphedema or are a primary cause of its complications. In patients with stage III (elephantiasis) LE, fibrosis and skin hardening/thickening cause significant skin changes. This intervention will also help the healthcare provider administer the necessary measures to help with poor wound healing as a result of skin deterioration.
Offer moisturizers or emollients to keep skin hydrated.	It hydrates hardened and dry skin and inhibits the development of hyperkeratosis.
Maintain routine skincare.	Patients are at risk of infections since the lymphatic system is impaired and circulation is disrupted. This inhibits the normal lymphatic clearance of invading pathogens, allowing them to infiltrate adjacent tissues, proliferate, and induce a local inflammatory response.
Educate the patient about necessary precautions, such as avoiding sun exposure, refraining from activities that can cause lacerations, abrasions, wounds, and burns, and maintaining adequate hand hygiene. Provide instructions on proper handwashing and request a return demonstration.	Excessive sun exposure can result in sunburns and place additional stress on a compromised lymphatic system.

Lymphedema Nursing Care Plan 4

Fluid Volume Excess

Nursing diagnosis: Fluid Volume Excess related to excessive lymph buildup, secondary to lymphedema, as evidenced by tachycardia, weight changes, pitting, hypertension, pulmonary edema, and 10 mm Hg central venous pressure (CVP)

Desired Outcome: The patient will conform to fluid and dietary limitations and will maintain a stable weight.

Lymphedema Nursing Interventions	Rationale
Examine the patient’s medical history and report for the presence of lymphedema, hypertension, tachycardia, and CVP.	Reviewing a patient’s medical history can aid in the decision-making process and active patient management. The presence of distal and dependent edema on the legs and feet, along with other indicators, suggests an excess of fluid volume. Venous hypertension is also a useful diagnostic indicator as it coexists with lymphoedema and can indicate venous insufficiency and fluid overload,
Monitor for changes in mentation and motor skills. Note for the presence of seizures and muscle twitching.	These evaluations aid in determining the presence of electrolyte imbalance and water intoxication following surgery, both of which are caused by the high volume of fluid used during intraoperative irrigation.
Examine the tibia, ankles, and sacrum for evidence of pitting and edema.	Aids in the differential diagnosis. Edema and lymphedema may be confused with each other. The buildup of fluid in the extravascular areas and non-pitting upon pressing the finger is the characteristic of edema, whereas LE is the opposite. Differential diagnoses should also include pathological sodium retention, dysregulation of the lymphatic system, increased hydrostatic pressure, and inflammation.
Raise the injured limb above heart level and handle with caution/care.	Elevating the afflicted limb counteracts blood and lymph pooling caused by the force of gravity.
Report the patient’s fluid intake and output.	Indicates whether the patient has fluid retention or fluid loss. Failure of the lymphatic system to drain excess fluids and solutes can reduce the volume of the capillary fluid, resulting in an increase in protein content, oncotic pressure, and fluid retention in the microcirculation.
Consider the necessity for therapeutic thoracentesis or paracentesis to minimize chyle accumulation, as indicated.	The accumulation of lymphatic fluid in the pleural space can result in spontaneous chylothorax due to a dysfunction or disturbance in lymphatic circulation. Chylous effusions may be drained percutaneously through para or thoracentesis; this procedure may also be suggested for postoperative patients with dyspnea and pain.

Lymphedema Nursing Care Plan 5

Risk For Ineffective Tissue Perfusion

Nursing Diagnosis: Risk for Ineffective tissue perfusion related to alterations in vascular inflow, secondary to lymphedema.

Desired Outcome: The patient will have adequate perfusion as indicated by the absence of chest pain, normal skin color, and skin temperature.

Lymphedema Nursing Interventions	Rationale
Evaluate the involved extremity for any indications of decreased tissue perfusion. Note: Quality of pulses, color, circumference, and sensation.	This assessment helps determine the presence and stage of LE.
Observe for changes in limb edema volume and measure the circumference of the affected and unaffected limbs.	This intervention offers insight into volume changes and permits comparison between the normal and affected limb. Since subtle variations in the extracellular volume are reflected in the circumference, it provides a clue as to whether the response to therapy is effective.
Avoid using a cuff for blood pressure measurements and refrain from intravenous administration, vaccination, and venipuncture in the affected arm.	These measures can constrict the lymphatic channels that contribute to LE.
Instruct the patient to wear compression garments and elastic bandages instead of tight-fitting clothing.	Clothing that is too snug might induce constriction, restricting lymphatic blood flow and providing potential sites for compromised skin integrity.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon

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