“Wet Legs” (Lymphorrhoea)

1. “Wet Legs” (Lymphorrhoea) Teresa Hill Lymphoedema Nurse Consultant Enfield Community Services Barnet, Enfield & Haringey Mental Health Trust

2. Lymphorhoea • Chronic oedema with leaking lymphorrhoea is a challenging condition both to live with from a patient’s perspective and to treat as a community nurse. • This condition is debilitating and has distressing effects on the patients. • It is essential that community nurses take a leading role in delivering effective person-centred care, which minimises the complications of the condition and eliminates hospital admissions as far as possible.

3. Aims of Wet Leg Pathway • The aim of this pathway is to support effective management of patients affected with ‘wet legs’ (lymphorrhoea) and chronic oedema on a community nursing caseload. • It is intended to be used by community nurses as a resource that can support a successful pathway of care. • This pathway will help community nurses deliver effective and timely chronic oedema management strategies ensuring delivery of prudent healthcare. Subsequently, improving the quality of life for those patients identified, as well as reducing the community nurse caseload.

4. Introduction • Chronic oedema with leaking lymphorrhoea frequently occurs within a community setting. • Lymphorrhoea is described as lymph leaking from oedematous tissues when breaks appear in the skin. Lymphorrhoea appears as beads of fluid which seep from the affected area, putting the patient at risk of skin damage and an increased risk of problems such as cellulitis. • Although frequently seen in the elderly population, it is also identified with younger patients who have had cerebral vascular attacks, spina bifida, paraplegia and multiple sclerosis. • Ensuring effective management, it is essential that community nurses can identify the aetiology contributing to chronic oedema and lymphorrhoea including the management strategies available. • A holistic assessment is required to determine the health history and any significant contributory medical conditions that would affect the implementation of compression e.g. uncontrolled heart failure, end-stage kidney disease.

5. Chronic oedema • Chronic oedema is a long-term condition where swelling occurs in the limbs for longer than three months. • Chronic oedema increases the risk of venous ulcers, and currently, 1% of the population have an ulcer. • Chronic oedema patients also suffer repeated cellulitis episodes and account for 2-3% of all hospital admissions. • According to a recent evaluation by Lymphoedema Network Wales, over 50% of community nursing time is treating people with chronic oedema and leg ulcers.

6. The pathways aims: • This pathway aims to manage patients with lymphorrhoea and chronic oedema promptly to reduce the risk of them developing chronic leg ulcers. With a rising elderly population, obesity, cardiac disease, cancer and three quarters of the population not getting enough exercise, the cases of chronic oedema are increasing. • The annual costs of leg ulcer management is£200million in the UK. Therefore it is vital that we implement chronic oedema management to reduce escalating costs from patients developing leg ulcers.

7. Effects of Lymphorrhea 1 • Chronic oedema affects individuals physically, psychologically and socially It has a significant impact on quality of life and the ability to undertake normal activities of daily living. • Reported issues include:- • Swollen limbs that can leak putrid fluid increasing isolation • Isolation which has the same effect on health as smoking 15 cigarettes a day • Poor functional ability due to co-morbidities which can lead to sleeping in a chair that increases chronic oedema • Decreased mobility causing extended periods sitting due to lifestyle choices and medical factors • Unable to wear normal shoes and limited on selection of clothes

8. Effects of Lymphorrhea 2 • Increased pain levels and increase risk of developing cellulitis and red leg syndrome • Unable to work - 42% of UK lymphoedema patients reported that the condition affected their ability to work5 and 9% had previously quit work due to the condition.10 It is, therefore, important to ensure chronic oedema is identified early and wet legs are managed promptly and effectively • Frequent unplanned admissions into hospital with cellulitis • Scared, anxious and depressed and unable to cope and lost control8

9. Research in Lymphorrhea • Research from Derby showed that patients with chronic oedema report that 50% had leg ulceration with 31% having an ulcer for more than five years. 11 Secondary complications included: • 53% suffered a cellulitis, of which 9% required hospital admission with 11 days being the average length of hospital • Inappropriate referrals cost a district nurse an average of 5 hours per week.

10. In 2016 in Wales • In June 2016, Cardiff and Vale University Health Board identified within an designated area, (population area 126,000) that 56% of the community nursing workload was managing chronic oedema and lymphorrhoea. • Management of these patients routinely involved the application of a wound dressing and yellow/blue line stockinette. This pilot identified patients were being seen at least once a day as the lymph fluid had soaked through the dressing.

11. Management Plan • The management plan included a full holistic assessment • A pathway for wet legs was produced and we have adapted this to help in the community nurse setting of Enfield. • This will be evaluated within our District Nursing teams.

12. Extra advice • As well as skin care and support bandaging, patients must also be encouraged to sleep in a bed and move their body accordingly. To promote behavioural changes and effective self-management, simple exercises

13. Once lymhorrhoea is controlled • It is important to note that once the lymphorrhoea is controlled, an individual assessment must be carried out to ensure correct compression garments are prescribed. The assessment can be done by a community nurse or collaboratively with the local lymphoedema service. Careful consideration of the social situation in how the compression garments will be applied and removed after lymphorrhoea management must be undertaken. A minimum of a minimum of a stocking liner (10mmHg) should be fitted. • We have formulated another care pathway and we will evaluate this with the District nurses

14. DISSCUSSION