[shalvoy.1]

Here are the articles Patti selected for us this session:

Larocque, G., & McDiarmid, S. (2019). The legacy of lymphedema: Impact on nursing practice and vascular access. Canadian Oncology Nursing Journal, 29(3), 194–203.

Reichart, K. (2017). Lymphedema. Clinical Journal of Oncology Nursing, 21(1), 21–25.

[gabel.164]

1.What was the knowledge gained from the article?
After reading, The Legacy of lymphedema: Impact on nursing practice and vascular access it provoked several questions on whether the my practice will be changed in the future. I think it’s the nurses responsibility to review the risk factors their patient has for lymphedema prior to obtaining peripheral vascular access ie. axillary node dissection, mastectomy, receiving chemotherapy, obesity > 30 BMI, and arm swelling.
Recently a medical oncologist here at SSCBC has questioned our policy on whether or not we should continue to avoid needles sticks on the affected arm due to recent research.
Our Policy:
Avoid IVs on the side of axillary node dissection, after radiation therapy, in the affected arm of
lymphedema or CVA patients or in patients with stage 4 or 5 kidney disease when possible. (Level
VII8)
The article Lymphedema. Clinical Journal of Oncology Nursing maybe question how well I assess my patient for lymphedema? I heavily use subjective symptoms when assessing my patient the only objective assessment I usual do in the infusion unit if the patient has unilateral swelling of the upper extremity.

2.Will the research/information in this article change or influence your practice? If so how? I feel I’m going to educate the patient on their overall risk and let the patient be part of the decision on whether or not the affected arm is used.
I think after reading these articles it has helped sharpen my assessment skills for subclinical lymphedema.
3.What other questions does the article raise about current practice? How well do we provide patients with surveillance for lymphedema for those patient’s at risk? Does our surgeons measure the patients arms preop and postop and if so for how long postop do they measure the patients?

I feel like this topic is still in a gray area as far as precautions on the affected arm. Personally, I’m always going to the unaffected arm first when any needle stick is needed. Why introduce that risk if it’s unnecessary.

4.Do you agree/disagree with the conclusions of the author, why? I agree with the author Reichart it is essential to have a protocol for Bioimpedance spectroscopy (BIS) and L-Dex device.

I agree with Larocque and and McDiarmid that long-held beliefs with regards to the risks factors and preventative measures need to be challenged, but I believe clinical data needs to be collected to support the use of the affected arm.

Larocque, G., & McDiarmid, S. (2019). The legacy of lymphedema: Impact on nursing practice and vascular access. Canadian Oncology Nursing Journal, 29(3), 194–203.
Reichart, K. (2017). Lymphedema. Clinical Journal of Oncology Nursing, 21(1), 21–25.

[pauley.18]

1. What was the knowledge gained from the article?

Lymphedema can be life altering for those that are experiencing the symptoms whether internally or externally. Healthcare providers that work within the population of patients that could develop lymphedema should be aware of the possible signs and symptoms these patients could have so as to address as quickly as possible. Nursing staff are the first to encounter the patient and in reading these articles I think that we are the ones who will be able to gather the patients early symptoms of lymphedema.

I work in the surgical oncology clinics at SSCBC and something we have implemented are the SOZO readings, which are the bioimpedence measurements, for our patients prior to any surgery that can involve the lymph nodes and then completed at certain intervals after surgery if multiple lymph nodes are removed. I didn’t realize though until reading the article by Larocque and McDiarmid that there has not been a consensus on the definition of lymphedema. I did know that lymphedema cannot be reversed, but managed to hopefully not worsen and this is the reason for the SOZO measurements prior to surgery.

I also learned that one patient that developed lympedema 30 years after a mastectomy and having repeated finger sticks is what seems to have prompted the papers on limb precautions.

2. Will the articles change my practice?

In my practice I work with all breast cancer patients and have had it ingrained in my assessment to ask the patient if there is a preferred arm for any BP measurements or if drawing lab specimens. I also am tasked with ensuring that if a patient is preop that they have a referral to physical therapy for the SOZO measurement if have any surgery involving their lymph nodes. We then have alert/prompts in patients follow up visits

3. What other questions does the article raise?

Something I question and so many of my other colleagues have as well is are limb precautions necessary due to the lack of recent research? Even this is too discussed in the article bu Larocque and McDiarmid. I know it sounds simple enough to try to study, but where is the time to do so?? And, this could really aide in patients that may already be a hard stick for blood specimens.

4. Do I agree with the authors of the articles?

As stated in answer three. I totally agree with Larocque and McDiarmid with regards to more recent studies being completed on the need for limb precautions. I realize that without knowing for sure, then this can inhibit our care provided at times with regards to obtaining lab specimens or proving IV medications.

[gabel.164]

Amoreena- Thanks for the surgical oncology voice when it pertains to these articles. I’ve only worked in infusion and medical oncology so it’s refreshing to hear what is being done on the surgical side.

It sounds from your response we’re very proactive here at the breast center because we do bioimpedence measurements for our patients prior to any surgery that can involve the lymph nodes and then completed at certain intervals after surgery if multiple lymph nodes are removed.
Are these measurements obtained by the lymphedema clinic?
Maybe you could help me, if I have a patient whom I’m concerned about lymphedema I usually get a consult with Physical therapy to be further evaluated? Is there anything else I should be doing to advocate for my patient?

• This reply was modified 5 years, 1 month ago by gabel.164.

[burk.109]

1. What was the knowledge gained from the article?
From reading these two articles I have learned many things. This first thing that I found interesting was that there are different stages of diagnosing lymphedema, ranging from no swelling at all to severe skin thickening. The other thing that I found interesting about these articles is that it is actually recommended that those with a risk of developing lymphedema should avoid air travel. When this is not possible, compression sleeves should be worn. I also learned that despite previous thoughts, exercise actually does not increase the risk for development of lymphedema.
2. Will the research/information in this article change or influence your practice? If so how?
The information in these articles will change the way I practice for the following reasons: I will provide education about travel to patients that have lymph node dissection. I also have more knowledge on what signs and symptoms to look for in order to refer the patient on to the appropriate department, if lymphedema became an issue.
3. What other questions does the article raise about current practice?
My biggest question in regard to this topic is the use of the affected arm for needle sticks. I always avoid the affected arm but would be interested in more findings on the use of the affected arm and how that increase prevalence of lymphedema. Also, many large cancer facilities appear to screen patients at risk prior to the development of symptoms but unfortunately I am not sure that is the practice among other facilities. Incorporating this in the standard of care may improve the incidence of lymphedema found in patients with node dissection overall.
4. Do you agree/disagree with the conclusions of the author, why?
In regard to the article by Gail Larocque and Sheryl McDiarmid, I agree with the c conclusions of the authors. I do think that doing less invasive techniques when appropriate and using a vascular access device is helpful to decrease the incidence of lymphedema. For the article by Kelly Reichart, DNP, RN I also agree with her conclusion. Developing and utilizing a plan to prevent and manage lymphedema is essential in comprehensive breast cancer care.

[burk.109]

I too believe that working at the breast center we have many resources that benefit our patients. I think that it is a great idea that in your daily practice you mark in the chart which arm can be used for blood pressures, etc. I have also ingrained it in my daily practice to ask which arm but it would be nice when “prepping” charts for the day if you had an idea without scraping the chart with a fine tooth comb! Also, I am quite interested in recent studies and data about use of the affected limb, it would be interesting to know exactly the percentage of increased risk with using it for various things.

[blackwell.72]

1.What was the knowledge gained from the article?
I learned a lot!
I did not realize you could asses those most at risk for lymphedema how that was measured. I knew we had lymphedema clinics but did not realize what all those visits entailed or how the patient was actually managed.
I also liked the grading scale that is used to rate the severity of the lymphedema. There are more interventions than I was aware of for those with less severe symptoms.

2.Will the research/information in this article change or influence your practice? If so how?
This will definitely change my practice:
I have surgical and medical gynecologic patients that often have pelvic lymph nodes removed. I will be paying closer attention to my assessments and inquiring if there are any interventions that can be done for my patients. I often offer referrals to lymphedema clinic but don’t “sell” it to my patients and often they feel nothing will help and decline. I will do a better job explaining what type of management and interventions they receive in that clinic. If I knew more about this, especially for the leg lymphedema I could be very effective in patient care since I manage both the gynecologic surgery and medical patient. I see them from the beginning of their journey, during treatment and for all regular follow up visits after completion of treatment.

3.What other questions does the article raise about current practice?
The biggest question I have is if this all holds true for leg lymphedema from pelvic lymph node removals. If not, how does it differ in assessment/prevention/management?

[pepper-king.1]

1. What was the knowledge gained from this article?
I learned a lot from these articles. Lymphedema isn’t something we talk about with our patients in Gyn/Onc unless it develops during their treatment. The biggest surprise for me was some centers don’t measure patients before they start their treatment. I would think getting this baseline information would be important in assessing for Lymphedema throughout their treatment.
I also learned that transient swelling does happen within the first year which increases the importance of measuring limbs before surgery.
Also, I didn’t realize so many restrictions were placed on people in the past to reduce the risk of Lymphedema like air travel, temperature extremes,and exercise. It looks like more recent studies have shown that air travel didn’t increased the risk of lymphedema and that women who wore the compression garments in this study had increased swelling. Exercise is recommended in progressive states to help with fatigue and quality of life. The paper does state to keep careful watch for symptoms of swelling during an exercise program so it can be addressed immediately.
There was a small mention of a study that suggested heat and microwave treatments for patients with lower extremity edema helped 75% of the patients reduce the swelling by 50%.

2. Will the research/information in this article change or influence your practice? If so how?
Yes. This makes me want to pay more attention to our patient population because they would be experiencing lymphedema in their lower extremities. As far as using limbs for blood draws and IVs I feel we need to continued get info on this. I do think the further out a person is from surgery, 5-10-15 years, and there is no lymphedema using that limb for blood draws and IVs is less of a risk. Of course it is ALWAYS up to the patient and if they don’t want that limb used then we don’t.

3.What other questions does the article raise about current practice?
Why do some centers not incorporate measurements and education about lymphedema?
What other studies are coming down the pike that may show we can use limbs that had nodes removed?

[gabel.164]

Last week I cared for a patient who had a PSH/PMH lumpectomy and radiation. She developed Upper Extremity Lymphedema four years after treatment. She was doing lawn work and unfortunately got several bug bites on the side of her lumpectomy/radiation. She had Upper Extremity swelling initially from the acute trauma which later developed into permanent lymphedema.

I wanted to share this story because it is a low life time risk for these patients. She stated that she has been selective on what shirts she buys because often her arm doesn’t fit into many shirts.

[burk.109]

Kelly-

I agree that it is shocking that some institutes don’t have anything in place for lymphedema management. As I said above, working at the breast center I think we have become a little spoiled working within a healthcare system that truly tries to get ahead of this. It would be interesting to me if other specialties within Ohio State are as vigilant with lymphedema prevention/management, in patients that are at risk. How common is this within the GYN population?

[blackwell.72]

WElcome to the discussion Kelly!

Kelly and Patty –
When you do chemo education do you discuss lymphedema and the baseline measuring etc,.? if so, I would like that in detail because I do not provide that information in my chemo teaching.

burk.109 (forgive me for not knowing your name) I am not that surprised that other institutions don’t take the precautions that The James does. It often seems that the others are not as up to date in their care which is terribly unfortunate.
When I worked in head and neck the lymphedema was only addressed if our assessments revealed the patient had discomfort or if they were concerned about it. There are (were) therapists that were specifically certified in Head/Neck lymphedema but I am not sure they were replaced when they left.

Mindy Blackwell

[pepper-king.1]

Mindy,

No, we don’t do lymphedema education with our patients during the chemo teachings. I would think the docs would when speaking to a new patient. But I will be more aware if patients complain of swelling in their legs during assessments for chemo. Honestly my first thought is ascites when our population’s legs begin to swell so this will make me go more in depth in my assessment.

[gabel.164]

Mindy,

I agree with Kelly I don’t include lymphedema in my initial chemo teaching. I feel that Chemo teaching is a lot of material to go over. I’ve usually addressed it when surgery is brought up. I guess after reading this article I should bring it up when patients have radiation as well.

[blackwell.72]

Thanks Patty and Kelly – I will not add to the chemo teaching. I actually do mention it when I do the surgery education and how in depth depends on what their procedure it. thanks!

[pepper-king.1]

Amoreena,

I agree more studies need to be conducted about limb precautions because yes it can start becoming difficult with starting IVs and blood draws in one arm. But my question is who would be willing to be part of a study like that? Maybe someone who is really having a lot of trouble with sticks in their good arm? I can see someone who doesn’t have lymphedema and doesn’t need or have trouble with IV sticks wanting to continue to protect that arm.
I guess i’m thankful we have other options like piccs and port if someone needs to do chemo again.

I would always use the good arm if possible too.

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