what to do if swollen legs are oozing

Lower-limb lymphorrhoea poses medical and practical challenges for patients and nurses, only can be avoided if lower-limb oedema is treated early on. This article comes with a self-cess enabling you to exam your knowledge afterwards reading it

Abstruse

The management of lower-limb lymphovenous illness and lymphorrhoea ('leaky legs') is challenging. The root cause of the disease must exist addressed and the take chances of infection minimised while symptoms are treated with pinch, dressings, topical agents and barrier products. Lymphorrhoea causes pregnant medical and practical issues for patients and nurses, just tin can be avoided if lower-limb oedema is treated early. This commodity describes the pathophysiology, direction strategies, and clinical and practical issues associated with the condition; information technology updates an commodity published in 2003.

Citation: Anderson I (2016) 'Leaky legs': strategies for the treatment and direction of lower-limb lymphorrhoea. Nursing Times; 113: 1, 50-53.

Author: Irene Anderson is national pedagogy fellow and principal lecturer (tissue viability), and reader in learning and teaching in healthcare do at the School of Health and Social Piece of work, University of Hertfordshire.

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 Introduction

The management of lymphorrhoea (grossly oedematous legs) poses major challenges because the condition is oftentimes accompanied by the leakage of considerable volumes of fluid – indeed the condition is commonly known as 'leaky legs' (Lymphoedema Framework, 2006). This article describes the pathophysiology of lymphovenous affliction, strategies to assist forbid or treat complications, and clinical and applied issues for patients and health professionals; information technology updates a previous Nursing Times article (Anderson, 2003a). Lymphorrhoea can touch on whatsoever limb (Renshaw, 2007), just this article focuses on the leg.

Lower-limb oedema

Lower-limb oedema showtime manifests as swelling at the ankle; if this is non controlled, swelling speedily extends to the pes and leg. Swelling is initially soft and 'pitting' simply, as the trouble becomes chronic, the tissues harden and it becomes increasingly difficult to reduce the oedema. In the early on stages, simply sleeping and sitting with the ankles elevated higher up hip level and applying mild pinch volition reverse the oedema, but if its crusade is non addressed, these measures will not prevent the status from condign chronic. The prevalence of diagnosed chronic oedema is around 4 per 1,000 of the Britain population, merely this figure is widely thought to be an underestimate (Todd, 2014).

Lymphovenous disease

Oedema occurs when capillary force per unit area exceeds the pressure of fluid in the tissues, causing fluid to leak from the circulatory system and accrue in the tissues (Lawrance, 2009). The lymphatic system is responsible for fluid drainage, simply if filtration from the capillaries (Fig 1) and venules exceeds drainage chapters for besides long, limb swelling occurs (Mortimer and Rockson, 2014). The blood circulation and lymphatic systems belong to a network (Fig 2), so extra congestion and force per unit area in the circulatory organisation leads to actress volume and force per unit area in the lymphatic system, increasing the leakage of fluid into tissues.

Lymphoedema occurs when a problem in the lymphatic drainage system causes fluid to accumulate in the tissues; it can be primary (whereby a genetic trigger causes the arrangement to fail) or secondary (whereby trauma causes the failure). Sometimes the drainage vessels can exist damaged by infection such as cellulitis (Lymphoedema Support Network, 2015).

Chronic oedema is caused by problems with venous return. This commonly happens because the valves in the veins fail to close properly, resulting in a backflow of venous blood leading to higher than normal pressures in the veins (venous hypertension). The additional blood causes the venous walls to stretch and plasma to leak into the tissues; the veins are unable to drain the fluid back from the tissues considering they are already congested.

Lower-limb oedema tends to be a mix of all the in a higher place, and is known as lymphovenous illness (Rockson, 2010).

Lymphorrhoea

Understanding of the fluid drainage mechanism has evolved in contempo years. There is now more than emphasis on the role of the lymphatic organisation to bleed interstitial fluid (fluid in the tissues), rather than on venules in the circulatory organisation reabsorbing interstitial fluid (Jacob and Chappell, 2013). At that place is nonetheless much that we practice not sympathize (Levick and Michel, 2010), but we know that improving lymphatic drainage every bit much as possible is a priority.

As lymphovenous disease progresses, especially if information technology is not well managed, legs tin become grossly oedematous; swelling causes the peel to stretch and small blisters appear. Fluid then leaks out and has nowhere to go considering both drainage systems (circulatory and lymphatic) are likewise congested (Elwell and Craven, 2015). The leg appears shiny with moisture or, more normally, fluid is seen running down the leg (Elwell and Craven, 2015).

The fluid leaking from the leg is transudate (fluid that has passed through a membrane); it has high fluidity and depression protein content (as opposed to wound exudate).

Implications for patients

Patients with lymphorrhoea report intense pain (Lymphoedema Framework, 2006) due to swelling, likewise as irritation, maceration (whitening and 'bogginess') and excoriation (redness and rawness) of the pare due to wetness. Somewhen the peel breaks down into at to the lowest degree 1 ulcerated expanse, and the risk of infection increases (Quéré and Sneddon, 2012). Patients likewise experience loftier levels of discomfort, embarrassment and inconvenience, not to mention expenses. They have to live with a leg that is extremely swollen and heavier than normal – imagine trying to walk up or downward stairs with a limb so heavy yous can barely lift it, or to walk without being able to flex your ankles considering they are and then swollen. Patients volition too exist constantly wet and take permanently wet footwear, dress and bedding (Morgan et al, 2011).

Risk of infection

If fluid accumulates in the tissues and is not tuckered, there is a run a risk of infection. The lymphatic organization is a primal element of the immune system, and so if it is compromised, the risk of infection from seemingly minor factors, such as scratches or insect bites, increases and can quickly become serious (Mortimer and Rockson, 2014). In lymphorrhoea, the skin is broken and very moisture, which increases the risk of infection; the take a chance of sepsis is also high (Elwell and Craven, 2015). Astute infection itself results in tissue oedema, and volition therefore add to the existing oedema.

Cellulitis is a potentially life-threatening subdermal and subcutaneous tissue infection commonly caused past Streptococcus pyogenes (two-thirds of cases) and Staphylococcus aureus. It is treated with oral antibiotics in milder cases, or intravenous antibiotics warranting hospital admission in more than severe cases (Opoku, 2015). Erysipelas is an infection affecting the superficial layers of the skin and is oftentimes acquired past group A beta-haemolytic streptococci. Cellulitis and erysipelas, which are often indistinguishable just almost always unilateral (Opoku, 2015), occur in patients with lymphovenous disease and lymphorrhoea.

Treatment strategies

Treatment of lymphovenous disease hinges on the use of compression, leg elevation and exercises that increase movement in the talocrural joint and calf muscles (O'Meara et al, 2012). Oedema must be managed to reduce congestion and swelling merely treating infection, if present, is a priority. In the presence of infection, the skin will be particularly vulnerable to breakup and the patient may experience intense pain, and then compression and limb management volition need to be conducted more frequently, and compression can be applied at lower pressures than normal. Once the infection is nether control, management tin focus on reducing swelling and leakage.

Managing lymphorrhoea tin be extremely difficult. There are many reports of patients resorting to placing their leg in plastic bags or using nappies, germ-free towels or incontinence pads in an endeavour to manage the volume of fluid. Nurses may use multiple dressings, which will need to be changed oft; this is both plush and time-consuming.

Compression

Compression comes in many shapes and forms, including bandages, hosiery, wrap systems and pneumatic compression. The key is to select a technique that applies force per unit area firm plenty to annul the tissue pressure, thereby squeezing the veins and valves to stop the backwards period of venous blood. This will reduce pressure in the veins and lymphatic vessels, assuasive more fluid to flow back into the drainage organization (O'Meara et al, 2012).

Sustained compression will reduce swelling; the correct compression volition effect in a fairly rapid reduction of oedema, and then information technology must be frequently readjusted to ensure a tight plenty squeeze on the leg. When bandages are used, they must be reapplied as soon as they feel loose. When large volumes of fluid are leaking it may be necessary to apply more than sub-bandage padding than usual, but this can be reduced one time the leakage diminishes (Renshaw, 2007). Renshaw (2007) suggests that short-stretch bandaging can exist more than comfy than medium- or long-stretch, as it applies a low pressure when the patient is resting.

Hosiery is not normally used when the leg is leaking, because applying and removing it when the pare is so fragile increases the risk of trauma, while constant contact with wet cloth can also harm the skin. Nonetheless, once lymphorrhoea is under command, hosiery can assistance reduce swelling (Lymphoedema Framework, 2006). If compression hosiery is to be used, the leg will demand to be re-measured to ensure the correct size is used.

The newer wrap systems tin be adjusted in situ, just if at that place has been a significant reduction in limb size, they will need to be re-measured and cutting. Patients may be able to make adjustments themselves, simply re-measuring and cutting or replacing the wrap system must be done by a health professional person.

Whatever system is called, information technology must exist acceptable and tolerable for the patient. In the acute treatment phase, materials that have become wet will demand to be frequently inverse – cost-effective materials should, therefore, exist used.

Dressings

Dressing technology has steadily improved in the past decade. Modern materials such every bit alginate, hydrofibres and absorptive granules increment the capacity of dressings to absorb fluid. While almost dressings are absorbent to some degree, some are particularly absorbent and are often called 'super absorbents'. Other innovations include gelling fibres – complex fibre structures and/or silicone – and products that control the management of fluid flow to protect the peel (Cowan, 2016).

Despite these advances, many challenges remain. The quantity of fluid can apace exceed dressing capacity, while it tin can exist hard to observe dressings that are large enough if the whole leg is leaking. Equally dressings are absorptive, they accumulate a lot of fluid, becoming heavy and prone to slippage; this may pull and tear skin that is already vulnerable. Some dressings are absorbent because they are bulky, and then they make an already-swollen limb even bigger.

Ane of the principles of compression is that higher pressures are applied on smaller circumferences and so that a larger circumference results in lower sub-cast pressure level (Thomas, 2014); this means that, when at that place is a lot of actress padding calculation to limb circumference, there is a risk that not enough force per unit area is being exerted on the leg. When super-absorptive dressings are swollen with fluid, they may exert boosted localised pressure, leading to changes in the pressure profile and possibly to pressure impairment.

Nurses should refer to local dressing formularies and discuss any challenges with a tissue viability nurse or other professional person with responsibility for the formulary. Whichever dressing is selected, it should be a comfortable fit, and should not cause discomfort when it has reached its absorbency chapters, or hold exudate against periwound skin.

Topical agents

Some astringent and mildly antiseptic substances are used on very wet skin, but their efficacy is debated. Treating very moisture skin with topical substances is a challenge; decisions must sometimes be based on clinical experience rather than evidence, every bit there is niggling evidence on the subject area. The central objective is to manage the underlying problem and non use topical agents for prolonged periods. For example, potassium permanganate solutions tin can help in acute episodes of lymphorrhoea but should non be used for more than 10 days (Elwell and Craven, 2015). They must exist used and disposed of according to the manufacturer's instructions, and so skin, nails, clothing and household items are protected from staining (Nazarko, 2013). Although the evidence base is weak, potassium permanganate is reported to be useful in wet, weeping legs. Its employ should be discontinued when the leg dries (Anderson, 2003b).

Antimicrobial agents such as silver, iodine and dearest can be applied, especially in the presence of wounds, when there is an infection or when the run a risk of infection is loftier. Current practice is non to use them for more than ii weeks at a fourth dimension, so their employ must be judiciously timed (Beldon, 2014). Dressings containing antimicrobials should be selected to provide maximum absorbency and comfort.

Barrier products

In lymphorrhoea, skin integrity is compromised not only by the swelling and fluid, but likewise the enzymes contained in the fluid, which tin can destroy healthy tissue (Adderley, 2010). The skin therefore needs to exist protected with products that isolate it from the fluid. So-called bulwark products come up in various forms, including creams, sprays and sticks. Silicone plays a key role: information technology forms a blanket that the fluid sits on, rather than resting directly on the skin. Manufacturers' instructions must exist followed carefully so the quantity of product applied is sufficient to create a bulwark merely does not hinder normal vapour loss through the skin (Draelos, 2012).

Diuretics

Both Al-Niaimi and Cox (2009) and Mortimer and Levick (2004) land that diuretics are not generally helpful in the direction of lymphovenous illness. Keast et al (2015) add that there is no, or merely minimal, response to diuretics in chronic oedema acquired by lymphovenous disease. However, lower-limb swelling and fluid leakage can take various causes, including renal disease, cancer, drug therapy and heart failure (Keeley, 2008), and diuretics may aid reduce lower-limb oedema caused past heart failure (Khatib, 2011). If middle failure is the underlying problem and across advisable medical management, compression therapy may exist contraindicated; it should simply exist used under specialist supervision until arterial catamenia to the extremities is determined (Peak et al, 2009).

Practical issues

In their study of circuitous lymphoedema, Morgan et al (2011) highlighted a link betwixt obesity and lymphoedema and the increased incidence of lymphorrhoea. They also explored issues effectually patients' behavior and motivation to participate in their treatment plans. This study focused on lymphoedema, only the management of chronic oedema involves many of the same issues, especially in patients with heavy and already-vulnerable limbs.

Specialist equipment such equally therapy couches may be required to manage heavy patients. Sometimes ii health professionals are needed to launder the patient, employ topical treatments and/or barrier products, cast limbs and treat lymphorrhoea (Morgan et al, 2011). Nurses must exist prepared to deliver 'intensive care' for the leg in the early stages, which will help avoid complications and ultimately exist less plush and risky than having to manage wet and swollen legs over long periods.

From a nursing perspective, patient management consists mostly of pain control (Lymphoedema Framework, 2006) and local management of the fluid. If diuretics are used, patients volition demand additional support to manage increased urine output, both in terms of actress visits to the toilet and skin integrity; this may make some patients reluctant to have diuretics. Practicalities and implications must be discussed with patients when handling is beingness planned; recording the progress of therapy can be useful to motivate them (Box 1).

Box 1. Documenting progress

Documenting assessments, treatments and outcomes is a requirement of good professional exercise (Nursing and Midwifery Council, 2015), but it is also part of good management and can be motivating for patients and nurses akin.

Regularly measuring limb circumference at the ankle and calf allows nurses to evaluate the effect of treatment. Sketches or, better still, skilful-quality photographs, will also help gauge progress and detect whatever deterioration or breakup of the skin, thereby enabling complications to be treated early. Measurements and sketches/photographs also back up good communication between health professionals, such as when a full general practice nurse needs specialist advice.

When taking pictures of patients, nurses must follow local policies regarding consent and data direction (Institute of Medical Illustrators, 2012).

Conclusion

Managing oedematous and leaking legs is a clinical challenge for health professionals and for patients. Nurses need to recognise what is happening and seek to accost the root crusade, while using absorbent materials and, where possible, compression therapy to reduce the accumulation of fluid. Cellulitis tin be prevented by expert oedema and peel management, just if information technology does occur information technology must be treated every bit a priority. An 'intensive treatment' approach to lower-limb oedema in the early stages will avoid many complications, including lymphorrhoea, that arise if the condition is not well managed. Box 2 lists online resources that tin exist used to back up direction plans.

Fundamental points

• Grossly oedematous and leaking legs nowadays direction challenges for both nurses and patients
• Patients with lymphorrhoea experience enormous medical and practical problems
• The nurse's part is to address the crusade of lymphovenous affliction while reducing fluid accumulation, leg swelling and hazard of infection
• If cellulitis occurs it must exist treated equally a priority
• Proactive direction of lower-limb oedema equally soon every bit it presents helps to avert complications such as lymphorrhoea

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