20
WOUND CARE TODAY
2015,Vol 2, No 1
FOCUS ON OEDEMA
›
of the lymphatic system, leading
to poor lymph drainage; whereas
secondary lymphoedema is caused
by damage to the lymph system
through an extrinsic process, e.g.
radiotherapy, infection such as
cellulitis, obesity, surgery, trauma and
lymphadenopathy due to cancer.
Lymphoedema swelling is a
mixture of both fibro-fatty tissue
and fluid. The early stages of
lymphoedema are often ignored by
both patient and clinicians since there
are no distinctive clinical signs and
the initial swelling can be relieved
with limb elevation during the day or
overnight (Williams, 2003).
However, as the fluid and waste
products accumulate in the tissues
they becomes harder and non-pitting
(‘pitting’ is where an indentation
caused by pressing with a finger
persists for some time after the
release of the pressure), and any
swelling will not reduce on elevation.
The International Society for
Lymphology (2003) has developed
a scale for the assessment and
categorisation of lymphoedema
(
Table 1
)
Venous oedema (hypertension)
If the venous system is damaged
or not working correctly, this will
cause venous insufficiency, where
the blood flows back down into
the veins leading to an increase in
blood volume and pressure. As a
result, the walls of the veins stretch
and the pores in the capillary wall
enlarge, allowing fluid, red cells and
protein to leak out into the tissues.
This increased load also puts extra
pressure on the perforating and
superficial veins. As these veins
stretch, their valves do not close
properly so they cannot prevent
a backflow of blood into the
lower limb.
Veins can be damaged by deep
vein thrombosis (DVT), which results
in scarring and which may hamper
venous return. The valves inside
the veins may not work because of
traumatic damage, e.g. surgery or
fracture; or will be unable to close
because the vein is swollen due to
congestion.
This situation can be made worse
if the foot and calf muscle pump
are not working effectively. For
example, when the muscle is weak
or has limited movement in people
who are immobile or elderly, it will
not compress the veins sufficiently
to propel the blood up towards the
heart (Moffatt, 2000).
As the volume of blood within
the veins increases, fluid begins
to leak out. Chronic venous
hypertension that has not been
treated will lead to venous oedema
in the lower limbs (Green and
Mason, 2006). The continuous
unrelieved pressure on the venous
circulation overloads the lymphatic
system, reducing its capacity to
remove fluid from the tissues, thus
causing oedema. Initially, the tissue
will be soft and pitting and elevation
can help to reduce the swelling.
present with oedema undergo
a comprehensive assessment to
establish the underlying cause of
oedema. Simply treating the clinical
signs and symptoms, e.g. dressing
a venous leg ulcer but not applying
compression that supports venous
return and lymph drainage will only
palliate the symptoms.
Different types of oedema have
their own symptoms and accurate
diagnosis can be difficult. The
common types of oedema include:
›
Lymphoedema
›
Venous oedema
›
Dependency oedema
›
Cardiac oedema
›
Oedema with obesity
›
Oedema of multiple aetiology.
Lymphoedema
Lymphoedema occurs as a result
of an accumulation of fluid and
other elements (i.e. proteins) in the
interstitial spaces due to a failure
of lymph drainage. Lymphoedema
arises from congenital malformation
of the lymphatic system, or damage/
loss of lymphatic vessels and/or
lymph nodes (International Society of
Lymphology, 2003).
Lymphoedema can be divided
into primary and secondary classes.
Primary lymphoedema occurs due to
an abnormality in the development
›
Wound facts...
Holistic assessment is the basis for
identification of the underlying
pathology so that effective
treatment can be implemented in
concordance with the patient.
Table 2:
Classification of venous disease: CEAP (clinical, aetiology, anatomy,
pathophysiology) (Berridge et al, 2010)
Classification
(category)
Description
Recommendations
C0
›
No visible or palpable signs of
venous disease
›
None
C1
›
Telangiectasias or reticular veins
(spider veins)
›
Lifestyle advice exercise, elevation, and
compression hosiery
C2
›
Plus varicose veins (over 3mm)
›
As above
C3
›
Plus oedema
›
As above — if no improvement
refer appropriately
C4
›
Changes in skin and subcutaneous
tissue, including pigmentation,
eczema, lipodermatosclerosis, or
atrophie blanch
›
Refer to vascular surgeon for full clinical
and duplex ultrasound assessment
C5
›
Plus healed venous ulcer
›
As above
C6
›
Active venous ulcer that has failed to
heal within two weeks
›
Urgent referral within two weeks.
Note: urgent referrals also apply
if there is bleeding, varicosities, or
superficial thrombophlebitis
