HOLISTIC ASSESSMENT Take 5 Imagine these legs are yours. Take a minute to imagine how they would impact on; - Your life at home - Your relationships – partner, children - Your job - How you feel about yourself? The Impact of Chronic Oedema • Impaired mobility – reduced range of movement in affected limb joints • Functional restriction • Difficulty with self care & hygiene • Swelling - inability to wear rings and watches , difficulty fitting into clothes • Skin Changes – skin tight and shiny, feels taut • Heaviness Pain caused by: • Skin tightness • Reduced function • Muscle Strain, weight pulling on soft tissue structures, e.g. tendons, ligaments • Nerve compression • Inflammation or infection • Tingling, Pins and Needles - indicator of neuropathic pain, not relieved by normal analgesia. • Reduced employment opportunities • Social isolation • Affects body image, self esteem and personal relationships (Moffatt et al, 2003) Assessment • • • • • • History Taking Assessment of swelling Assessment of skin condition Pain assessment Psycho-social assessment Vascular assessment History taking • Medical history – previous & current – Arthritis, cancer, cardiac, renal, trauma, surgery • Current medication - some exacerbate oedema • • • • • • Family history – oedema/venous/cardiac/renal weight history Presenting symptoms – onset Mobility & functional assessment Previous treatments? Allergies Assessment of swelling - ? Pitting, press and hold for 10 seconds - measurements of limb – baseline for comparison Stemmer Sign Positive Stemmer's sign - inability to pinch fold of skin at base of second toe due to thickening. Diagnostic of Lymphoedema Assessment of skin condition The general condition of the patient’s skin should be assessed for: • Hydration (eg dryness) • Pigmentation/lipodermatosclerosis • Eczema • Redness/pallor/cyanosis • Warmth /coolness • Signs of cellulitis • Broken or ulcerated skin • Fungal infections – toes and skin folds (eg Tinea Pedis) Pain assessment • Use pain assessment tools – Wong Baker • Pain Assessment & Management Information Sheet – Nociceptive or Neuropathic? Abbey Pain Scale for the measurement of pain for people who cannot verbalize. Score following a 5 minute observation. NO PAIN SCORE = 0-2 (No intervention), MILD = 3-7 (Administer drugs observe effect) MODERATE = 8-13 (Administer drugs observe effect) SEVERE =14 plus (Seek help immediately) Affix RiO Label Vocalization: e.g. crying, groaning, whimpering, Absent 0 / Mild 1 / Mod 2 / Sev 3 Facial Expression: Looking tense, frowning, grimacing Absent 0 / Mild 1 / Mod 2 / Sev 3 Change in body language: Fidgeting, rocking, withdrawal Absent 0 / Mild 1 / Mod 2 / Sev 3 Behavioral changes: Increasing confusion, change in sleep pattern, not eating, reluctant to move or receive care. Absent 0 / Mild 1 / Mod 2 / Sev 3 Physiological changes: (for acute pain) Pulse, Pallor Absent 0 / Mild 1 / Mod 2 / Sev 3 Physical changes: Pressure sore, injury, contracture Absent 0 / Mild 1 / Mod 2 / Sev 3 Total Score Signature Date Date Date Time Time Time Psycho-social Assessment • • • • Effects of swelling on day to day life Screen for depression Occupation – past & present Care and social support mechanisms • Body image issues • Expectations of treatment Vascular Assessment All patients must be assessed to establish their vascular status • Doppler ABPI is the standard - Ok to compress ABPI of 0.8 to 1.2 • Difficult on very oedematous limbs • Lower limb assessment tool • Toe brachial pressure index Take 5 The patient arrives for their appointment and this is what you are faced with: 1. What do you do & why? 2. What do you think your chances of improving these legs are? Please jot your thoughts down Management 1. Skin care 2. Lymphatic drainage (MLD / SLD) 3. Exercise 4. Compression therapy 5. Pain management 6. Psychological support 7. Nutritional support Skin Care Vitally important to maintain skin integrity, prevent the development of hard or dry skin, and reduce the risk of infection: • Encourage a daily skin care regimen & self care (or at each dressing change) • Wash with soap substitute – wash off old emollient • Dry gently – thoroughly into skin folds & between toes • Apply regular emollients in downwards motion(not between toes) – emollient formulary • Removal of skin scales Hyperkeratosis Prevent – daily skin care regimen & compression Treat – use emollients that contain urea Wipes & squirting saline are NOT effective Needs bucket of warm water, flannel & emollient (Hydromol Ointment) Folliculitis • A pustular inflammation of superficial hair follicles caused by bacteria • Caused by application of emollients in upwards direction • If left untreated cellulitis may develop Varicose Eczema • Gravitational eczema is found in a large number of patients with chronic oedema • It is associated with poor venous return • It is managed through the use of Compression therapy, leg elevation, emollients • Use topical steroid OINTMENT when it is flares up, potent for 2 weeks reducing down Cellulitis Management • Prevent acute inflammatory episodes (cellulitis) by meticulous skin care • Each episode further damages lymphatics • Prompt treatment is essential to prevent further damage that can predispose to recurrent attacks. Cellulitis Treatment • Acute cellulitis – 2 weeks antibiotics • 2 or more attacks per year – prophylactic antibiotics • This is the BLS consensus for treatment of cellulitis: http://www.thebls.com/consensus.php Cellulitis or Red Legs? Cellulitis Symptoms Red Legs YES Temperature/fever NO YES Feeling unwell NO YES Pain YES Redness which spreads YES Heat More tenderness No More warmth Lymphatic drainage Manual / Simple (MLD / SLD) • Repetitive light pressure movements on the skin at a slow rhythm. • Movement mimics the action of lymph flow in the body. • Stimulates lymphatics to function more effectively • Only available privately or in the Lymphoedema clinic BUT, they don’t do legs! Exercise, Movement & Leg Elevation The importance of movement can not be underestimated • Optimize flexibility & prevents stiffness • Improve muscle pump action • Enhance lymph and venous return Exercise Suggestions: • Tailored to the patient’s individual level of ability • look at current levels of activity and encourage patients to identify ways to increase them • Activating the calf muscle by circulating, flexing and dorsiflexing the feet • Frequent short walks • Compression garments should be worn during exercises • ‘Generations Games’ – DVD, classes, buddies • Elevate legs when sitting • DO NOT SLEEP IN THE CHAIR! Pain Management • Identify cause & treat eg cellulitis • Nociceptive & neuropathic analgesia – Amitriptyline at night? • Education & positive reinforcement • Pain –> poor sleep –> depression -> pain cycle Psychological Support • Engage & empower patients in their care – decision making & self care, setting goals • Talking Spaces - for the treatment of depression and anxiety • Talking Health - Coping with physical health problems using psychological therapies • Medication Nutritional Support Oxfordshire weight Loss Service • • The programmes have been developed with long-term results in mind, to help participants understand more about their weight and the drivers of their behaviours. MoreLife also work with clients to reinforce positive behaviours and challenge behaviours that have a negative impact on their health Compression Compression • Hosiery – early stages – Maintenance – continuing care • Bandaging – to decongest the limb prior to moving to maintenance with hosiery – With ulceration/lymphorrhoea – Distorted limb shape Compression Hosiery Hosiery is divided into classes which depends on the amount of mmHg delivered at the ankle and there are variations between British and European standard. Classification BRITISH: Level of mmHg EUROPEAN: Level of mmHg Class 1 14 – 17mmHg 18 – 21mmHg Class 2 18 – 24mmHg 23 – 32mmHg Class 3 25 – 35mmHg 34 – 46mmHg The CHROSS Checker • The CHRonic Oedema Signs and Symptoms • CHROSS Checker chart and key cards • Helps identify skin changes – as a result of underlying venous and lympho-venous disease • As part of a Holistic Patient Assessment • Clear guidance on which compression products can be used to manage the disease type Key Card CHROSS Checker Form • European (EU) Class garments - RAL • For management of oedema, chronic oedema & lymphoedema • Stiffness of garments oppose limb oedema • Available on FP10 / GP10 Actilymph – ‘off the shelf’ • European class • 3 classes / 5 sizes - sand • Below knee open & closed toe & thigh length open toe available in black • 2 leg lengths (below knee) • 2 welt widths, both with grip top Please watch the following video: The rule of thumb is that off-the-shelf compression hosiery sizes will generally fit 80% of patients. Made to Measure Hosiery • You may ONLY measure for MTM hosiery AFTER you have attended this hosiery workshop and received the correct training • ‘Off the shelf’ hosiery is your 1st line option • Only consider MTM after 1st measuring the limb for ‘off the peg’ hosiery and confirming it does not fit within these measurements Measuring for hosiery • Measurement guides are provided by the manufacturer but always include ankle circumference • Measurements should be taken as early in the morning as possible, before the patient has been standing for long periods of time, or straight after removal of bandages • Patients who require compression hosiery for each leg must have both legs measured because they may be different sizes. • Measurements need to be taken next to the skin to ensure accuracy • Take measurements in standing position for thigh hosiery, sitting or standing for calf & ankle • If sitting the knee should be flexed to 90 degrees and foot on the floor • Use a sheet of paper to measure the foot length • Check accuracy of measuring tape- old tapes stretch with time Practical session MTM Order Form 1. Fill in your name and mobile number Order ref. - the patient's name 2. The measurements - two columns - in cm l = measurements of length DO NOT follow the contours of the body. Measure vertically to the ground c = measurements of circumference c & l are measured in stages up the limb • Use a pen to mark the spot • The positions for each point are described on the inside cover of the pad eg B1 - where the calf starts 3. Panty. - DO NOT ORDER - £150/pair!! Only in particular circumstances Difficult to measure Refer to tissue viability if you think you need them 4. Ankle pads - AS ABOVE, DON'T ORDER 5. Oblique toe – to protect little toes How high? As high as the oedema! Below knee if no oedema to knee or above: - prevent ulcer recurrence - DVT - Measurements A-D Thigh length If the knee is swollen or there is oedema above the knee. • A - G measurements • Point G is 2cm below the gluteal fold • If you want to finish lower – measure F above the knee and G wherever you want the stockings to finish Thigh high with waist attachment For thigh high oedema with risk of hosiery rolling at the top • Can have both legs in this at the same time Options 1. Open toe - allows access to toes - podiatry • - to check circulation if staying on for eg 1 week 2. Closed toe - if there is oedema to the foot +/- oblique toe - l A1 and l A2 Top band • NB unless you specify otherwise below knee will come without any kind of top band!! • 3cm available for below knee only • 5cm also available for thigh T Heel ankle seam • This gives a little extra room around the front of the ankle so it doesn't dig in • Always choose this 7- back of the form MTM practical • Please pair up with someone and measure one of their legs for MTM thigh length hosiery • Complete the measurement form choosing from the options re colour, top band etc and selecting the relevant codes Hosiery applicators Actiglide Magnide – see video Friends & family Continuing care – Delegated Health Task Self Care Compression Other garments – to facilitate self care by patients Farrowwrap Juxtafit Please refer to TV if you think your patient would benefit. Not everyone is suitable.
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project