CASE STUDY: TREATING SYSTEMIC PRIMARY LYMPHEDEMA BY PHYLLIS TUBBS-GINGERICH, RN, BSN, LE, CLT-LANA
In December, a Blood Vascular Physician phoned saying that one of his patients was in ICU “drowning in his own fluids”. The physician explained in detail his patient’s condition: He had been hospitalized in ICU for over one month, had been treated with many different diuretics with no success, a Foley catheter was in place and there was very little urine output, he was totally immobile due to fibrosis of body tissues and joints, over one liter of fluid was being removed from his lung cavity every day, he was on an air mattress to prevent bed sores, and was breathing by means of a ventilator through his tracheostomy.
My first visit for evaluation of this patient in ICU confirmed his very acute, critical medical condition:
1. The small amount of dark brown urine in the urinary collection bag signified that very few body fluids were “moving” and those being excreted were highly concentrated.
2. A total fibrotic condition of all body tissues and joints existed leaving the patient “locked in” with hard tissue, immobile joints and the patient flat on his back.
My first priority was to “get the patient up and moving” without compounding already existing problems or causing additional problems for the patient. Treatment had to be done cautiously and gradually so as to not overload his heart and lungs.
Treatment began with short stretch bandages wrapped gradiently over a directional flow garment (DFG) and applied to the left leg only, toes to groin. His wife was instructed in manual lymph drainage (MLD) to stimulate the peripheral lymphatics to move fluids out of the left leg, up over the abdomen and into the left axilla. Constant MLD during this phase was requested because of the patient’s severe lymphedema condition. Also, the success of this treatment protocol was dependent upon: if this particular gradient bandaging plus this specific MLD would relieve his body of hardened fibrotic tissue fluids, increase excretion of fluids and thus, reduce volume and relieve symptoms.
On the onset, it was necessary for us to evaluate and monitor effects before proceeding and expanding treatment protocol.
Rational: Gradient bandaging applied over a DFG breaks up fibrosis and softens tissues, and repeated MLD moves fluids out of congested areas into pathways where body fluids can ultimately be excreted.
After 3 hours of bandaging with constant MLD, the urinary collection bag was full and had to be emptied. By the 3rd treatment day, both lower legs were bandaged, the patient’s wife and family were performing MLD bilaterally and the patient was able to get up and walk around his ICU room. And, the urinary collection bag was constantly being emptied.
Rationale: Movement and muscular activity, with resistance on the skin in the form of gradient compression, softens tissues and body fluids move from the toes up the leg. The action of MLD further assists movement of fluids out of affected areas into collateral pathways where they can be excreted.
On the 10th day of treatment, the patient was moved from ICU into a private hospital room, his family was assisting with bandaging and performing MLD, and he was awaiting discharge for the Christmas holidays.
Rationale: lymphedema is a chronic condition and must be maintained daily. Therefore, most patients, especially gravely affected patients, need the help and support of their family to assist them with their daily care.
On December 22, the patient was fit in knee-high gradient compression garments bilaterally. And, when asked how much weight he had lost since his hospital admission seven weeks prior, he said the scales that morning weighed him at 100 lbs. lighter. He stated that he felt so good and that he was really looking forward to being home with family and friends for Christmas. “I never ever thought I’d be home to celebrate Christmas this year.”