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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
208
Figure 5−82 Measurement form for neck and chin compression garments and compression face masks (with
permission from JUZO, Inc.).
5 Treatment
209
Patient Education
Providing patients with appropriate informa-
tion and education facilitates long-term
success of lymphedema management. A dial-
ogue between the patient and the lym-
phedema therapist covering all relevant
aspects of lymphedema management should
be initiated early on in the intensive phase of
the treatment. Sufficient knowledge of the
patient regarding his or her condition is the
key to compliance. Patients need to know what
causes lymphedema to understand fully why
self-management is a necessary component of
CDT (easy to understand terms should be used;
a sample patient information form is given in
Chapter 6, Information on Lymphedema).
Patients should be informed about the possible
consequences if self-care for lymphedema is
neglected. Knowledge about the risks involved
in certain activities (air travel, extremes in
temperature, etc.) helps to avoid the recur-
rence of symptoms.
At the end of the intensive phase, the patient
should have the necessary skills to perform
self-bandaging and self-MLD techniques safely
and effectively and to execute a customized
program of decongestive exercises. A thorough
understanding in preventive measures (see
Do’s and Don’ts for Upper Extremity Lymph-
edema and Do’s and Don’ts for Lower Extrem-
ity Lymphedema later in this chapter) as well
as high- and medium-risk activities for lymph-
edema should be achieved at the time the
patient transitions into phase 2 of the treat-
ment.
Self-Bandaging
During the intensive phase of the therapy
(phase 1), the compression bandages applied
by the therapist may slide somewhat over the
treatment-free weekend days. Sliding is usu-
ally limited to the upper arm or thigh. The
patient should be able to reapply the bandages
in these areas to avoid reaccumulation of fluid
and/or tourniquet effects caused by bunching
up of the compression bandages. It is therefore
necessary to involve the patient in the bandag-
ing process as soon and as much as possible. At
the end of the first week of treatment, the
patient should be able to apply padding and
compression bandages on the proximal parts
of the extremity without major difficulty.
Figure 5−84 Measurement form for compression vest (with permission from JUZO, Inc.).
Patient Education
210
To maintain and improve the success
achieved in the first phase of treatment and to
further reduce and soften areas of fibrotic
tissue, most patients have to continue to wear
bandages at night. Even patients who do not
experience an increase in extremity volume
during the nighttime and who do not have any
areas of fibrotic tissue may experience fluctua-
tion in limb volume at times (lifestyle, during
menstrual period, weight gain, climate, etc.). It
is therefore imperative for long-term success
that every patient learns appropriate self-ban-
daging techniques while under the care of an
experienced and properly trained lymph-
edema therapist.
To support patient compliance, it is essential
to keep the self-bandaging techniques as
simple as possible. It cannot be expected that a
patient will be able to use the same techniques
as the lymphedema therapist. The use of high-
density foam without the supervision of the
clinician is not advisable. Bandages in the self-
management phase are primarily worn at
nighttime, when the patient sits or lies down.
Much less bandage pressure is needed to
achieve the beneficial effects of compression
therapy. The quantity of materials is therefore
much lower than during the intensive phase of
therapy, during which the compression ban-
dages are worn 22 to 23 hours a day.
Upper Extremity
The following is a list of the recommended
materials for applying a compression bandage
during the night on the upper extremity (self-
management phase). The quantities represent
two sets of compression bandages, which are
recommended for hygienic reasons (one to
wear and one to wash):
쐌
1 bottle of skin lotion
쐌
1 box of stockinette (tubular bandage) in
the appropriate size
쐌
1−2 boxes (20 individual rolls in a box) of
gauze bandages (4 or 6 cm width)
쐌
2−4 synthetic nonwoven padding bandages
(10 cm) or 2 Rosidal Soft foam bandages
(10 cm)
쐌
2 short-stretch bandages (4 or 6 cm)
쐌
2−4 short-stretch bandages (10 or 12 cm)
쐌
Tape to secure the bandages
Application. Bandages generally are applied
with an even prestretch of 苲30 to 40 % and an
overlap of 苲50 to 70%. The patient should
apply the bandages while sitting at a table.
All materials should be arranged in the order
in which they are applied; two or three strips
of tape per compression bandage (苲5 inches
long) should be prepared. Padding bandages
are not taped.
Skin care: Appropriate skin care products are
applied thoroughly, without causing redness
of the skin.
Stockinette: The tubular bandage should be
cut to a length that allows for an overlap of 苲5
inches on the proximal end of the extremity.
This overlap is used to extend over and cover
the complete compression bandage on the
proximal border to protect it from axillar per-
spiration. A hole is cut for the thumb on the
distal end.
Finger bandages: Fingers are slightly spread,
and the palm of the hand faces down. A bolster
should be placed under the elbow to support
the weight of the arm.
Start the gauze bandage with a loose anchor
turn around the wrist, then proceed over the
back of the hand to the little finger (or the
thumb). The fingers should be bandaged with
light pressure from the nail bed up with 苲50 %
overlap (Fig.5−85). The fingertips are not
covered. Leave the finger with the gauze band-
age toward the back of the hand and proceed to
the wrist; apply a half turn (complete anchor-
ing turns should be avoided) around the wrist,
and continue to bandage the remaining fingers
in the same fashion. The borders of the gauze
bandage should not slide or roll in on the distal
and proximal ends of the fingers. One gauze
bandage is generally used to bandage all fin-
gers. Any unused part of the second gauze
bandage should be wrapped spirally (not
circular) around the forearm. The finger band-
age should never start or end at a finger. Upon
completion, the fingertips should be checked
for proper circulation.
Padding materials: Nonwoven synthetic pad-
ding or soft foam rolls (Rosidal Soft) are used to
pad the hand and arm. A hole is cut for the
thumb; the padding bandage is secured
around the wrist with a circular turn. The hand
is then padded down to the knuckles using two
5 Treatment
211
to four circular turns (Fig. 5−86). The padding
bandage proceeds to cover the forearm and
upper arm. Two rolls of padding bandages are
used to cover the hand and arm (Fig. 5−87). Do
not use tape to secure the padding materials.
Short-stretch bandages: Starting a 6 cm (or
4 cm) wide bandage with a loose anchor turn
around the wrist, the hand is bandaged to in-
clude the knuckles with slightly spread fingers
(Fig. 5−88). The bandage is anchored between
Figure 5−86 Application of synthetic
padding bandages on the hand, includ-
ing the knuckles.
Figure 5−87 Padding of the arm
using synthetic padding bandages.
Figure 5−85 Application of gauze
bandages on the fingers.
Patient Education
212
Figure 5−88 Application of short-
stretch bandages on the hand and
wrist.
Figure 5−89 The remaining short-
stretch bandage is used to apply com-
pression on the forearm.
Figure 5−90 Application of the sec-
ond short-stretch bandage starting at
the wrist.
each turn around the hand with half turns on
the wrist. Any remaining bandage material is
used on the forearm (Fig. 5−89). The end of the
bandage is secured with two strips of tape. The
subsequent bandage (10 or 12 cm) is applied in
the opposite direction of the first bandage. This
provides for a more functional and durable
bandage. The bandage starts on the wrist with
a loose anchor and proceeds to cover the fore-
arm, elbow area, and upper arm with circular
turns and 苲50 % overlap (Fig. 5−90). A third
bandage may be used if necessary. It is impor-
5 Treatment
213
tant that the last bandage ends in the axillary
fold to prevent accumulation of fluid between
the armpit and the end of the bandage (Fig.
5−91).
The end of the bandage is secured with two
or three strips of tape, and the overlap of the
stockinette is folded over the bandage.
Lower Extremity
Following is a list of the recommended materi-
als for applying a compression bandage on the
lower extremity during the self-management
phase of CDT (phase 2). The quantities repre-
sent two sets of compression bandages, which
are recommended for hygienic reasons (one to
wear and one to wash):
쐌
1 bottle of skin lotion
쐌
1 box of stockinette (tubular bandage) in
the appropriate size
쐌
If toe bandages are necessary:1−2 boxes of
gauze bandages (4 cm width)
쐌
2 high-density foam pieces (kidney-
shaped)
쐌
3−5 synthetic nonwoven padding bandages
(10 cm) or 2 Rosidal Soft foam bandages
(10 cm)
쐌
2−4 synthetic nonwoven padding bandages
(15 cm) or 2 Rosidal Soft foam bandages
(15 cm)
쐌
4−6 short-stretch bandages (10 cm) or 2
double-length (11 yards) 10 cm rolls
쐌
4−6 short-stretch bandages (12 cm) or 2
double-length (11 yards) 12 cm rolls
쐌
Tape to secure the bandages
쐌
If necessary: additional foam pieces pro-
vided by the therapist
Application. Bandages generally are applied
with an even prestretch of 苲30 to 40 % and an
overlap of 苲50 to 70%. All materials should be
arranged in the order in which they are ap-
plied; two or three strips of tape per compres-
sion bandage (苲5 inches long) should be pre-
pared. Padding bandages are not taped.
To bandage the foot and the lower leg, the
patient should be sitting, with the foot of the
affected leg resting on another chair or on the
knee of the other leg. Bandages from the knee
up to the groin are applied while standing.
Skin care: Appropriate skin care products are
applied thoroughly, without causing redness
on the skin.
Stockinette: The tubular bandage should be
cut to a length that allows for an overlap of 苲5
inches on the proximal end of the extremity.
This overlap is used to extend over and cover
the complete compression bandage on the
proximal border (Fig. 5−92).
Toe bandages (if necessary): Start the first
gauze bandage with a loose anchor turn
around the foot, then proceed to bandage the
big toe. Enter the toe from the dorsum of the
foot, apply two or three circular turns, and
Figure 5−91 Finished compression
bandage on the upper extremity.
Patient Education
214
leave the toe again over the dorsum of the
foot. Avoid sliding or rolling of the bandages
in the web space area. The tips of the toes re-
main unbandaged. Proceed to bandage the re-
maining toes (except the fifth toe, which
generally is not involved in the swelling) in
the same manner. One 4 cm bandage (usually
folded to half width) is generally sufficient to
cover the toes. Any unused part of the gauze
bandage should be wrapped spirally (not
circular) around the foot. Upon completion,
the tips of the toes should be checked for
proper circulation.
Padding materials: Two or three rolls of non-
woven synthetic padding, or one or two rolls of
soft foam (Rosidal Soft) are applied on the foot
and lower leg (Fig. 5−93). Komprex foam kid-
neys are secured between the medial and
lateral anklebone and the Achilles tendon with
the padding bandages. Synthetic padding
bandages may be doubled over the shin area to
provide additional protection.
Short-stretch bandages: Starting a 10 cm wide
bandage with a loose anchor turn around the
foot, the foot is bandaged down to the web
spaces with three or four circular turns (Fig.
5−94). The same bandage proceeds to cover
the heel in a crisscross fashion. During the ap-
plication of compression bandages on the heel,
the ankle is in 苲70 to 90 degrees of flexion
(Figs. 5−95, 5−96). Secure the bandage with
tape. The next bandage (10 cm) starts above
the ankle with a loose anchor in the opposite
direction of the previous bandage (applying
compression bandages in the opposite direc-
tion to each other prevents bandaging the foot
in a nonfunctional position; i.e., it provides for
a functional bandage and adds durability). The
goal is to cover the lower leg up to the knee
using circular turns (Figs. 5−97, 5−98). Secure
Figure 5−92 Application of stock-
inette on the leg.
Figure 5−93 Application of synthetic
padding bandages on the foot, ankle,
and lower leg.
5 Treatment
215
Figure 5−94 Start of the first short-
stretch bandage with a loose anchor
around the foot.
Figure 5−95 The ankle is in 70 to 90
degrees of flexion while applying band-
ages around the heel.
Figure 5−96 Short-stretch bandages
around the ankle are applied in a criss-
cross fashion.
Figure 5−97 The second short-stretch
bandage starts with a loose anchor
around the ankle.
Patient Education
216
the bandage on the lower leg with tape. If a
double-length bandage is used, the foot as well
as the lower leg may b e bandaged using the
same roll.
The remaining compression bandage is ap-
plied while standing up, and the body weight
should be shifted to the extremity being
bandaged, with the knee slightly bent. Pad-
ding materials using nonwoven synthetic pad-
ding or soft foam rolls are applied on the knee
and thigh (Fig. 5−99). When using synthetic
padding bandages, the layers may be doubled
in the back of the knee to provide additional
protection. The knee and thigh should be
bandaged using two or three rolls of 12 cm
wide short-stretch bandages (or one double-
length roll). The first bandage starts with a
loose anchor turn below the knee, proceeding
to cover the knee and parts of the thigh using
circular techniques (Fig. 5−100). The remain-
ing thigh is bandaged with the next bandage
roll. Secure the bandage with tape, and fold
the overlap of the stockinette over the ban-
dage (Fig. 5−101).
Decongestive Exercises
The following exercises serve as guidelines for
an exercise program that can be performed by
the patient without major difficulties during
the decongestive and self-management phases
of therapy. The exercise protocol may be
changed to accommodate the patient’s limita-
tions. Generally, the exercise program should
not be too difficult or too lengthy to perform,
and the movements must not cause discom-
Figure 5−98 Application of short-
stretch bandages on the lower leg.
Figure 5−99 Application of synthetic
padding bandages on the knee and
thigh.
5 Treatment
217
Figure 5−100 Application of short-
stretch bandages on the knee and
thigh.
Figure 5−101 Finished compression
bandage on the leg.
fort, pain, or soreness in the musculature. The
affected extremity should be elevated as often
as possible during the day.
Ideally, the exercises are performed 10 to 15
minutes following the MLD session, and the
patient should rest with the limb elevated for
苲10 to 15 minutes after the exercises.
Stretching exercises (yoga), swimming,
water aerobics, and walking are beneficial ad-
ditions to the decongestive exercise program.
Higher impact activities (e.g., step aerobics)
may exacerbate lymphedema and should be
avoided. A summary of high- and medium-risk
activities for patients with upper and lower ex-
tremity lymphedema are listed in Do’s and
Don’ts for Upper Extremity Lymphedema and
Do’s and Don’ts for Lower Extremity Lym-
phedema in this chapter.
Upper Extremity
쐌
Exercises should be performed wearing
compression bandages or compression
sleeves (except when exercises are per-
formed in the water).
쐌
Tight or restrictive clothing (tight under-
wear or bra, heavy breast prosthesis) should
not be worn while performing the exer-
cises.
쐌
Exercises should be performed twice daily
for 苲10 to 15 minutes. The duration of the
Patient Education