Compliance with the care plan can be a thorny issue in the realm of the treatment of swelling and edema.
Patient compliance (or lack of compliance) is a major issue for many clinicians. At times, it can be one of the biggest barriers to implementing a care plan. This lack of patient compliance can be particularly noticeable when the suggested intervention is painful, unpleasant, or challenging- which edema management certainly can be!
Of course we know, people who are dealing with an issue that brings them to our services have already been through a lot! By the time we see someone in physical/occupational/speech therapy, or are providing nursing care, they are already overwhelmed. They might feel beat, exhausted, or just want to give up already! Does this sound familiar?
Here, we outline how to ensure your patient is as compliant as possible with your treatment plan for their swelling and edema.
Explain their condition… in a way that they understand!
Chronic edema is a condition that can be surrounded by misunderstanding and incomplete information. There can be a conception that swelling, especially when is is initially caused by trauma or an acute event (injury, surgery, etc), will just “go away by itself”. This misconception is not only untrue, it can be actively damaging! This lack of understanding of how the lymphatic system works can lead to ‘acute’ swelling developing into a chronic, unmoving lymphedema.
However, a patient whose edema is brought to your attention as a problem- it may be impacting their mobility, placing them at higher risk of falls, leading to infections or chronic skin breakdown- might have an incorrect perception that their swelling will disappear once the offending cause (Diabetes, Trauma, CHF… the list goes on) is under control. Unfortunately, this isn’t the case!
If left to persist in the extremity, edema can overwhelm and ‘wear down’ the lymphatic system, leading to a high-protein lymphedema. This can be recognized through some of the characteristic skin conditions that are associated with chronic edema.
We, as clinicians, may understand the importance of addressing edema as early as possible- but the first step in getting buy-in from your patient is getting them to realize this, too! Depending on their level of health literacy, you may want to use a metaphor or mnemonic to help them remember this complicated concept. You can explain: the lymphatic system is working away like a train- chugging away and removing the additional fluid as fast as it can- but over time and being worked at maximal capacity, the engine and wheels begin to wear and fail, and it can’t transport its load as efficiently as before. Over time, it becomes slow and worn and then cannot even transport a light load efficiently.
Show them the outcomes of their efforts
Gaining patient compliance and buy-in, especially when you need them to be active participants in decreasing their swelling and edema, is going to hinge on their understanding the value and results.
Edema management is multi-faceted. Complete Decongestive Therapy is an umbrella term, encompassing the main tenets of edema management- including Manual Lymphatic Drainage, Compression Bandaging, Decongestive Exercises, Skin Care, and Patient Education. For your patient to be compliant with this course of action, they will want to see the outcomes of their efforts.
Taking girth measurements, and explaining the difference between limbs (“your right leg is 25% bigger than your left!”); or- if both limbs are affected equally- “your limbs are 20 cm smaller in total this week than 2 weeks ago!”. It can be incredibly motivating to know that the work they are doing- and it is work, even if it is ‘just’ wearing their compression stockings!- is having a measurable effect on the size of their limbs.
Taking regular progress photos, and tracking the photographic changes over the days and weeks that you are working with your patient can be extremely effective. The condition of their skin, the girth of the limb and general improved appearance may be a more compelling reason to stay the course with regard to treatment plans than all the didactic education in the world.
I had a non-compliant patient in my care in in-patient rehab, who had presented with LE cellulitis, amongst other conditions (pics of hyperkeratosis leg, arrows to conditions). I was able to convince her to a trial of treatment, which included proximal MLD, impregnated gauze on the areas of hyperkeratosis, compression bandaging with chip pads to soften fibrosis, and exercise. Within a week I was able to show her this progress picture (see before/after pic). Despite being resistant to the idea of Complete Decongestive Therapy to decrease her infections, improve her skin and general outcomes, the photographic progress was more compelling to her as a reason to persist with the plan of care.
And lastly- use their own subjective reports to show them the difference in their function. With chronic edema, the person has likely had a slow and steady decline in function, that may have affected their mobility, pain and fatigue levels, perceived endurance, skin feel/breakdown, and so on. You may be able to show your patient- “When we first met, you needed assistance swinging your legs out of bed and reported it was a Rate of perceived exertion of 8; today you did it yourself and told me it was closer to a 2!”. Hearing their own subjective reports as to how difficult some tasks had been, before engaging in their plan of care, may be more personal and engaging to them. This may help with compliance with regard to edema management; the memory of how difficult some items have been will probably not be long-forgotten.
Listen; and meet them where they are at
‘Buying in’ to a plan of care may be the last thing your already overspent patient wants to do. And you may have an idea in your mind as to what they ‘need’- thorough manual lymphatic drainage, high levels of foam and compression bandaging with short stretch bandages, and daily decongestive exercises, for example. If this is too overwhelming for your patient- you may get a very resistive response. This is where your skilled, careful listening will come in.
Once explaining what you want to achieve and work on with your patient, you should listen closely. They may agree to you plan ostensibly, but not follow through- or instead, can resist you completely. Try to hear what their biggest concerns are, and if you can modify or water down your ‘perfect’ plan, do it! Any intervention will be better than no input whatsoever. Although the best intervention might include a short stretch bandaging complex- if this is too bulky and labor-intensive, you can explore other options. These other options may be less effective, or work less quickly, but are still preferable to no intervention. Off the shelf garments that can be less bulky and obvious, such as the Exo line from L&R, may be a more acceptable solution.
Make it easy!
Going through the rehabilitative process is hard enough! Try to make compliance with your proposed plan as easy as possible for your person. Teach them self management techniques- and make sure they are as simple as possible! (Check out some videos teaching simple proximal drainage techniques, right here)
This also follows into compression- make sure that you provide your patient with the tools they need to be able to don it as easily as possible. The Slippie Gator can be a helpful aid for donning compression stockings. ReadyWraps are an extremely intuitive compression garment, that your patient can adjust and continue to decongest in.
Decongestive exercises can be made easier by tying them to an existing home exercise program, that your patient may already be familiar with. Decongestive exercises are simple and straightforward, and anchoring them to a routine or existing program will help make them more intuitive to include into daily life.
Building healthy habits for edema management, including skin care and risk reduction, is vital. Examine, with your patient, how you can make this as intuitive as possible!
Patient compliance in the management of edema and swelling has long been a tricky issue. By following some of these techniques, you may be able to help reach your patient where they are at, and engage them fully in their plan.
If you found this compliance article helpful, you would love our popular and engaging seminar on the topic of Edema Management! Check it out and read more right here: Edema Management in In-patient Rehabilitation!
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