Case Study: August-September 1999
This study was of a 47-year-old white, female.
Her physical diagnoses are:
Paraplegia
Lymphedema - right lower extremity
Hypertension
Past history- lower extremity ulcerations / ce!lulitis
For the past 5 years the patient' s right lower extremity lymphedema has
intensified. Lymphedema sequential pumps were instituted approximately 5 years
ago. The patient wore graded support hose to the knee, which she was unable to
remove and wore continuously for approximately the first two years. As time
passed, the edema began to increase, not allowing her to wear the support hose.
She began to utilize the lymphedema pumps on an irregular basis, as the edema
would return almost immediately after lowering her leg onto the wheelchair
foot-lift.
In May 1999, I was asked to evaluate patient's right lower extremity for severe
4++ edema from toes to below knee. The patient was experiencing transfer
difficulties due to the weight of her extremity. She had reduced her out of home
exposure due to the visual change from the severe edema in the extremity. Upon
evaluation, the patient' s epidermis on the right lower extremity was stretched
to cover an enormous sized leg and foot which neither the patient nor I could
independently lift with any ease due to the weight of the extremity. The distal
digits (toes) were swollen to the level of vascular constriction causing
cyanosis of the nail beds and digits. The epidermis on the leg was extremely
dry, cracked and discolored. The fifth toe had been previously amputated due to
osteomyelitis and circulation compromise. The average right lower extremity's
measurements were calf- 16", ankle- 16" and foot- l3".
Due to HTN 160/114 and tachycardia (90-120), it was decided that the patient
should be cleared by the cardiologist, urologist, and family physician to obtain
cardiac / renal function stability and blood pressure control before lymphedema
reduction could begin.
The patient agreed to be an active member of the team, which included taking the
prescribed blood pressure Rx on schedule in order to obtain a blood pressure
control. This would allow the use of the lymphedema pumps and the support
devices needed to control the swelling.
After the physicians' permissions were obtained and her B/P and pulse rate were
reduced with the use of Vasotec and Cardura (Rx), the lymphedema pumps from toes
to upper thigh were re-instituted in a graduated process. Pumping began at a
daily 1-hour limit as long as V/S remained WNL. After approximately 4 days, the
pumping was increased to BID with our goal of TID reached within 2 weeks. Slow
edema reduction in the lower extremity occurred but the ankle and foot remained
very taunt and very edematous.
The problem of a graded support device was on the forefront. The patient, due to
paraplegia, spends the majority of her time in a wheelchair dangling her lower
extremities. Elevated foot lifts were not a functional option. The circulation
in the extremities was questionable. Due to massive edema, paraplegia, and the
inability to apply support hose, an easy to apply edema containment device would
be needed. A search for such a product was instituted.
After viewing the new product (CircAid) by Coloplast at the National WOCN
meeting in Minneapolis, Minnesota in June it was decided that a sample of the
product would be requested from the local representative. The representative and
the ET/NP made a joint visit with the patient and her husband. Due to her
husband's physical status he would not be able to assist with the application of
a difficult support hose device. The CircAid had very little pulling involvement
and used Velcro to secure it from below knee to the distal end of the dorsal
foot. Due to the patient's massive edema, which remained in the lower leg after
using the lymphedema pumps for over 2 weeks, the largest CircAid lower extremity
device was somewhat small allowing little to no compression at the ankle and
foot area. Demonstration and written information was left in the patient's home.
It was decided to try the device with the understanding that the patient and
husband would observe the extremity for any color or temperature changes. The
nursing visits through home care were increased to daily to monitor kidney
function, vital sign stability, and circulation
status. Abnormal signs and symptoms along with emergency instructions were left
with the patient and husband.
Upon returning after 24 hours of use, the CircAid had reduced the edema in the
proximal portion of the lower leg notably. The device then fit around the leg in
the fashion it was designed to do due to reduced edema. Toes circulation was a
continuous concern so the CircAid compression was applied with limited tension.
The lymphedema pump was used in the AM; the visiting nurse applied the CircAid
after the treatment. In the PM the CircAid was removed and the pumps were
reapplied for the hour prescribed. This schedule was continued for 3 days.
During this time period, the patient reported increased urine production; urine
from S/P remained clear, light yellow.
Upon completion of the 4th day of treatment with the CircAid, the patient had no
lower leg edema from below the knee to the ankle. The epidermis on the dorsal
foot was no longer taunt but was soft with no epidermis tension. The toes, even
though they received no compression support, had begun to show signs of edema
reduction and the return of normal skin color. The skin over the digits were
wrinkling post edema reduction. The patient reported she was experiencing easier
transfers due to a reduction of the lower extremity weight. The patient' s V/S
continued to improve with the prescribed Rx intake. The patient and husband's
participation was reinforced by the positive visible changes in the leg and
foot.
Within a week' s time the ankle edema was under control with the visualization
of the malleolus of the right ankle. Toe edema no longer existed and the dorsal
right foot was soft with a 1-2+ non-pitting edema. The area has had previous
scarring post tissue damage so we were expecting slower edema reduction in the
dorsal foot.
Two weeks into the therapy, a medium size CircAid device was requested from
Coloplast. The compression device fit the leg with the recommended over-lapping
to allow for a slight increase in the tension (compression).
Along with the "edema control treatment", a skin care program was
formulated. As edema reduction continued, the dry, flaking, discolored epidermis
began sloughing. Because of the reduced' edema the patient was able to transfer
into the shower with ease; cleansing the skin was done on a regular bases.
Moisturizers and vitamin E oil were used to encourage the return of soft, supple
epidermis. The toe nails' healthy appearance returned rapidly with edema
control.
The patient and her husband report "her leg has not been this skinny for
over 5 years". They expressed their support of the therapy and the CircAid
verbally as well as demonstrating the product to numerous friends who are also
paraplegic with similar edema conditions. As of mid September 1999, the right
lower extremity measured at calf 14", ankle 11" and dorsal foot
11" with no edema in upper or lower leg to ankle. Edema 2+ non-pitting with
scar tissue remains in dorsal fight foot; no edema is present in the toes of the
right foot. The extremity is not elevated but remains in dangling position on
wheelchair foot-rests the majority of the day. Edema reduction and control has
been maintained with the lymphedema pumps and the CircAid graded support device.
The patient' s physicians have all expressed amazement at the edema reduction
and control with the use of CircAid. Information on the product was supplied to
the physicians upon their request.
Approximately one month past the introduction of the CircAid, the patient and
her husband remain verbal supporters of the product. The lower extremity
epidermis remains slightly "wrinkled" in the areas where the severe
edema was. The lymphedema pumping has been reduced to daily with the use-of BID
if time is available. The edema did not return after the patient was unable to
utilize the pumps for over 48 hours; she continued to wear CircAid, removing it
at bedtime and reapplying it in the AM.
I feel this is such an amazing success story. The patient and her husband have
agreed to participate in this case study in
hopes this will assist other individuals who suffer from the disabling effects
of lymphedema.
This product has filled the void between the compression wraps and the tight,
uncomfortable graded (20-40 mm compression) support hose. Through my 23 years of
providing nursing care and patient support I have not found an "easier to
use" product with such dramatic effectiveness. Even the patient with
limited upper extremity strength, such as an arthritic patient, could use this
product to provided edema control.
Debra Moulavi
BSN, MS, ET, MSN, ARNP-C
Central Florida
Wound and Skin ConsuItants
PO Box 607521
Orlando, FL 32860-7521
