\ \ N \ ‘WW‘ IHII WH’ W: fit}, MINI LIBRARY Michigan State University SUPPLEMENTARY MATERIAK INBACKOFB PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6’01 cJCIHC/DltoDuo.p65-o.15 /SECONDARY LYMPHEDEMA: GUIDELINES TO PREVENTION AND MANAGEMENT FOR THE POSTSURGICAL OR POSTRADIATION CANCER PATIENT/ BY BARBARA ANN STARKE A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Nursing 1996 LIBRARY Michigan State University ABSTRACT SECONDARY LYMPHEDEMA: GUIDELINES TO PREVENTION AND MANAGEMENT FOR THE POSTSURGICAL OR POSTRADIATION CANCER PATIENT BY BARBARA ANN STARKE The causation of secondary lymphedema is not a mystery. Surgery and radiation therapies can result in lymph fluid obstruction, stagnation, and edema. Secondary lymphedema of the limbs due to cancer treatments can be debilitating, both physically and psychologically. It can be treated successfully by the application of “Complete Decongestive Physio- therapy”. Education of the patient about the prevention and management of lymphedema can be enhanced by the availability of an “information booklet”. Focus on the pathophysi- ology, management, and health promotive considerations after cancer treatment are offered to help prevent the nemesis of secondary lymphedema. ACKNOWLEDGMENTS Preparation of this project was supported in great part by Robert Lerner, M.D., Guenther Close, and Steve Norton of LB Services, Princeton, New Jersey. Their training and easy accessibility have provided me confidence in my most alone moments. Appreciation to Marge Whitman, R.N., MS, 0.08. for her generosity in sharing professional resources and personal encouragement, and to Joann Phillips of the St. Joseph, Michigan, Women’s Resource Center. Her tireless enthusiasm and energy to produce this project have taught me how important it is to share the load and work to- gether. A true mentor. To all my clients who teach me so much and encouraged me to put my ideas on paper. \Vith joy and pleasure, I thank you. Finally, to my dedicated faculty committee of Michigan State University’s College of Nursing. These women supported me throughout this process and helped me to see that, “Yes, there is a light at the end of the highway between Coloma and East Lansing.” TABLE OF CONTENTS INTRODUCTION .............................................................................................. 1 THE NEMESIS OF SECONDARY LYMPHEDEMA ......................................... 2 Definition of Terms ........................................................................................ 2 CONCEPTUAL FRAMEWORK ........................................................................ 6 The Health Belief Model ................................................................................ 6 Adult Learning Principles ............................................................................ 11 Literature Review .............................................................................................. 13 Methods ............................................................................................................ 14 Distribution ....................................................................................................... l 5 Evaluation ......................................................................................................... 15 Implications for Advanced Nursing Practice in Primary Care ............................. 16 BIBLIOGRAPHY ............................................................................................. 18 ii LIST OF FIGURES Figure 1 - The Health Belief Model ..................................................................... 7 Figure 2 - The problem of lymphedema (LE) management through the ' framework of the Health Belief Model ........................................................... 9 iii INTRODUCTION Secondary lymphedema (LE) can develop as a consequence of surgery and/or radiation treatment for cancer. It is a serious and compromising sequela traditionally discounted by the health care community in the United States. The ignorance and chaos that now exists produces misleading and unclear information that puts patients at risk of getting unsatisfactory treatment and experiencing unnecessary negative outcomes (Foldi, E., Foldi, M., Clodius, 1989). This scholarly project addresses the problem of secondary lymphedema by the development of a patient information brochure. It may be used by patients to understand, manage, and hopefully, prevent secondary LE. The practitioner in the primary care setting is in an optimal position to responsibly assess, educate, and empower patients to manage, if not totally prevent, secondary LE. Many more persons are being given early diagnosis and early treatment for cancer. Though cancer cells may be eradicated, the integrity of the inquinal or axillary contents and superficial lymphatic flow may be compromised. This will lead to a higher proportion of cancer patients at risk for developing cellulitis and/or lymphedema. If and when this occurs, it will probably be diagnosed by the primary care practitioner. THE NEMESIS OF SECONDARY LYMPHEDEMA Today’s health care arena of integrated systems is emphasizing cost- containment measures, prevention and health promotion measures for all citizens. The primary provider is being asked to identify and treat problems that in the very recent past may have only been seen by the specialist. Informational material on LB along with strategies to facilitate positive outcomes are both relevant and essential in the primary care setting. The product of this project is an information brochure which patients can use to manage lymphedema that occurs secondary to surgery and/or radiation treatments. There are two main goals for this brochure: 1) To inform patients on ways to prevent the onset or development of physical disabilities due to surgical or radiologic treatment for cancer, and 2) To inform patients about LE to lessen psychological complications due to impaired body image, social curiosity, emotional strain and mental preoccupation (Carter, 1993; Mirolo, Bunce, Chapman, Olsen, Eliadis, Hennessy, Ward, & Jones, 1995; Tobin, Lacey, Meyer, Mortimer, 1993; Dennis, 1993; McMorkle, 1995) Addressing the nemesis of LE through a patient information brochure that explains the conservative program of “Complete Decongestive Physiotherapy” (CDP), is an effective way of dealing with LE. CDP has been practiced in Europe for decades and is now getting established in the U. S. (VVrttlinger, G. &H., 1982) This multiphase regimen is being implemented by advanced practice nurses in private practice as well as those in hospital rehabilitation settings and private clinics. The impressive results of CDP allow for positive outcomes in situations where if left untreated or undertreated the LE could certainly have the potential of causing severe complications. Definition of Terms Secondary lymphedema is a chromic condition typically caused by obstruction of the initial lymphatics producing lymphostasis. The resulting protein accumulation produces inflammation and macrophage activity. Fibrosis of the interstitial connective tissue by fibrinogen and fibroblasts causes the development of the “brawny” (hard), non- pitting lymphedema that does not respond to elevation or elastic support devises. The involved limb is always at risk of developing infection and cellulitis due to lymph stasis (Brennan, 1992; Britton & Nelson, 1962). Persons who have undergone surgery and/or radiation therapy for cancer, especially those receiving dissections or radiation to either inquinal or axillary nodes are at risk of developing lymphedema throughout their lifetime. Prevention and education efforts are aimed at supporting health promoting/life giving choices that reduce the risk of compromised lymphatic flow (Larson & Weinstein, 1986). Complete Decongestive Physiotherapy (CDP) is a conservative and effective treatment regimen for secondary LE. It involves gentle manipulation of the skin to decompress lymph from the proximal and then the distal areas of the body. Manual lymph drainage (MLD) is the massage aspect of the CDP program. MLD breaks down areas of fibrosis allowing more efficient lymph flow. Empowering the client to engage in a regular gentle exercise program also improves lymph flow by muscle contraction squeezing fluid back to the vascular tree. Conscientious skin care, combined with diet education round out the treatment regime of CDP. As the treatment modality of choice for LE, CDP has a long successful history in Europe and Australia (Foldi, et al, 1989). Developed in the 1920’s by a German physician, Emil Vodder, it is a technique to bring about acceleration of lymph flow while eliciting a parasympathetic nervous system response (relaxation) (Wittlinger, 1982; Granda, 1994) There are four aspects of CDP: 1) Manual Lymph Drain (MLD) is a specialized form of massage to increase lymph vessel contractility and promote emptying and decompressing of lymph vessels and interstitial fluid. MLD improves lymph circulation, increases the volume of lymph fluid transported by abnormal and normal lymph vessels. MLD also breaks down fibrotic areas caused by proliferative connective tissue. The MLD session lasts about one hour and promotes a deep sense of relaxation. This relaxing modality is therapeutic in its abilities to mechanically promote lymphatic flow and also in its ability to act on the autonomic nervous system to promote a sense of calm well-being through its exceptionally gentle touch (F oldi, et a1, 1989). 2) Compression bandages are specially manufactured to be minimally elastic in their stretch potential. When applied to an enlarged limb the bandages increase the tissue pressure in the extremity and reduces the ultrafiltration rate in the interstitial fluid. They also improve the efficiency of the muscle and joint pumps and prevents the reaccumulation of evacuated lymph fluid. Finally, it helps break up deposits of accumulated scar and connective tissue (Miller, 1994). 3) Exercises are performed with the bandages or a support garment in place. Exercise increases lymph vessel activity. It also improves lymph and vascular circulation. Deep abdominal breathing increases the volume of lymph fluid transported to the thoracic duct. A general sense of well- being is attained through regular strengthening and flexibility exercises (Pender, 1987). 4) Meticulous skin care is emphasized to reduce the bacterial and fimgal populations on the involved limb since there is increased protein concentration interstitially and within the lymphatic vessels due to lymph stasis (Whitman & McDaniel, 1993). The person who has undergone a lymph node dissection, even with breast conservation (lumpectomy) will be at a lifetime risk of developing cellulitis in the affected arm (Simon & Cody, 1992). Education Material: Educational materials are part of the patient’s health care process. Informational material is aimed at producing a measurable change in behavior and/or attitudes. Benefits of using material to inform patients about lymphedema can help them gain increased independence, increased physical safety and emotional security, and help persons be more competent in recognizing signs and symptoms of infection due to impaired lymphatic flow. Peripheral Lymphatic Anatomy: An overview of peripheral lymphatic system is helpful to appreciate the pathophysiology of lymphedema. The lymphatic system is an interrelated yet functionally autonomous system linked with the neurologic as well as the endocrine systems. Lymphedema is a problem of peripheral lymphatic flow and the discussion will concentrate on those mechanisms and purposes of the lymphatic tree relevant to obstruction of that flow. All lymph fluid passes through lymph nodes. The significance of this phenomenon is that all pathogens entering the body must be identified, subdued, or otherwise destroyed to prevent overwhelming the body with infection, toxicity, or other negative consequences. This process starts in the initial lymphatic pathway in the intercellular space. Here, lymphocytes pick up the invading pathogen and transport it via lymph fluid to a lymph node. At the node the pathogen is presented to the T-cells, the immune system is upregulated with appropriate antibodies and the immune response is orchestrated. This is where “immune integrity” originates and this is why human beings need lymph fluid to pass through lymph nodes (Olszewski, 1985). Lymph nodes are superficial. Initial lymphatic pathways are superficial. The pathways begin in the superficial and dermal layers of the skin forming two plexus. These two plexuses cover the entire body. They provide a network of redundancy that provides the body superfluidity of vital life giving components and processes. It is this redundancy of the initial lymphatic pathways which provide protection in the event of trauma such as surgery or radiation. The redundancy provides alternate routes for lymph flow. If there is trauma or infection to a pathway collateral lymphatics can be challenged to develop and anastomose with the vascular system. Initial lymphatics originate in the capillary beds of the interstitial space. It is at those sites that oxygen, electrolytes, and nutrient molecules diffuse from the vascular capillaries into the interstitial spaces where they can be used by the cells. It is the movement of plasma proteins, primarily albumin, that promotes an even distribution of fluid flow. This is called the “colloid osmotic factor” and is the major force preventing edema throughout the body. It is the transport of albumin through the initial lymphatics which provides a major regulating force of tissue fluid volume. This system is vital in organizing the homeostatic mechanisms of the body. In summary, here is how the scenario of secondary LE progresses: The medical procedures damage the integrity of the superficial initial lymphatic system. Over time, months, maybe years, the progressive impaired flow in the superficial lymphatic circulation attracts an accumulation of cells, cell by products, and antigens. The stasis leads to a high protein edema, chronic inflammation, and fibrosis, known as lymphedema. CONCEPTUAL FRAMEWORK The Health Belief Model as modified by Becker (1974) provides a framework to understand how people determine to take action to prevent an illness or disease. Thus, it provides an excellent approach for the development of a patient information brochure for the management/prevention of secondary lymphedema. Concepts on the adult learner will be adopted from the work of adult education consultant, Malcolm Knowles (1988). The Health Belief Model The Health Belief Model (HBM) (Figure l) is a way of understanding what motivates an individual to avoid or prevent illness or disease. The model focuses on three areas: 1) individual perceptions 2) modifying factors and 3) likelihood of action. Four major characteristics of the individual help determine whether preventive action will occur: 1) perception of susceptibility to a disease 2) whether the perceived consequences would produce enough severity to the person’s life that she/he would act preventively believing that 3) the benefits of avoiding the disease would be higher than, 4) the barriers to overcoming the risks (Becker, 1974). Individual Perceptions Modifying Factors Likelihood of Action Demographic variables (age, sex, race, ethnicity, etc.) Sociopsychologic variables (personality, social class, peer and reference-group pressure, etc.) Structural variables (knowledge about the disease, prior contact with the disease, etc.) Perceived susceptibility to disease X Perceived seriousness (severity) of disease X i Perceived threat of disease X Cues to action Mass media campaigns Advice from others Reminder postcard from physician or dentist Illness of family member or friend Newspaper or magazine article FIGURE 1. The Health Belief Model. Perceived benefits of preventive action minus Perceived barriers to preventive action J, (.— Likelihood of taking recommended preventive health action The Health Belief Model will be adapted to the problem of secondary LE (Figure 2). Specific components of the model will be examined from the perspective of persons at risk of develOping secondary LE. Persons who have had their lymphatic pathways damaged or removed are at a lifetime risk of the limb swelling. The susceptibility of LE also increases with each bout of cellulitis due to the pathophysiology of inflammation in an already compromised limb (Simon & Cody, 1992). Individual Perceptions Perceived Susceptibility: The belief of a person’s susceptibility to a disease falls along a continuum from “high” to “low”. If the person considers the risks or chances of developing a disease far removed fiom their life then the chances of them investing much energy or resources to prevent the condition are small. Conversely, if the chances are seen as high that the condition is likely to occur in her/his lifetime, the effort and expenditure is likely to be significant (Becker, Drachman, Kirscht, I974; Fink, Shapiro, Roester, 1972). Perceived Seriousness Perceived seriousness has implications in many facets of a person’s life. It relates to how the condition would impact on the family, the work setting, the social circle and the relationships involved in each of these areas. The degree of severity may also have a negative impact on persons seeking to prevent disease or illness. If the perceived seriousness is too high it might thwart efforts to prevent the condition. If the perceived seriousness is too low, it may also deter action. Modifying Factors Many demographic variables such as age, sex, race, ethnicity, etc. may have a significant influence on the individual’s perceptions of susceptibility and severity. Prior contact with the disease, knowledge of the disease, and other “cues” to action can also Individual Perceptions Perceived susceptibility to LE Perceived severity to LE l-) Modifying Factors Likelihood of Action Demographic variables (age, sex, race, ethnicity) Sociopsychologic variables (support group/peers) Structural variables (knowledge of LE) mild LE -) prior contact with LE i Perceived threat of LE _ T Cues to action Written Information i.e. brochure Media campaigns Known ecquaintencel famity member with LE Advice from others '-) Perceived benefits of preventive action: i limb size i potential for limb loss l sense of well being I social well being/ community involvement T perception of victory over cancer minus Perceived barriers to preventive action: d e No out-of-pocket payment source 2. Physician denial of problem! severity 3. No access to treatment center 4. No support/reimbursement from 3rd party payers. i l—> Likelihood of action (CDP, exercise, compression wrapping, skin care) FIGURE 2. The problem of lymphedema (LE) management through the framework of the Health Belief Model. lO influence the individual’s “perceived threat” of a particular disease. Factors such as advice from others who have the condition, written material pertinent to the condition, all have an impact on the person’s likelihood to act. Implementing the Health Belief Model’s variables of “perceived susceptibility” and “perceived seriousness” is pertinent in a discussion of lymphedema post surgery or radiation treatment for cancer. Persons who have had their lymphatic pathways damaged or removed are at a lifetime risk of the limb swelling. The susceptibility of LB increases with each bout of cellulitis due to the pathophysiology of inflammation in a compromised limb. Educating patients about the risks and seriousness of potential infections and/or injury is vital to prevention of LE. Informing patients through an information brochure will serve as a “cue to action”. Items for inclusion are: 1) a definition of lymphedema, 2) back- ground information on the lymphatic system, 3) signs and symptoms of lymphedema, 4) general precautions, and 5) limb care to keep the extremity as normal in size as possible. Likelihood of Action The action called for is: 1) To be attentive to skin care of the involved limb. It is important to not injure or traumatize the limb to prevent the inflammatory response. Each bout of cellulitis produces an added fluid volume making limb size potentially larger with each infection. The benefit of attending to the limb is to prevent infections. A barrier to preventive actions are health care practitioners who deny the potential or severity of the problem. They unfortunately do not instruct patients to use antibiotic therapy either prophylactically or at the first sign of infection. 2) Exercise regularly to maintain “ideal body weight” and mobility of the involved limb. The benefit of exercise is to promote independent living. Again, a barrier to promotion of an exercise program is practitioner ignorance to the potential for lymphatic compromise. ll 3) If any swelling occurs seek therapy so that the limb may be evaluated for low- stretch compression wrapping to reduce ultrafiltration rate and swelling. Health practitioners erroneously prescribe a compression sleeve without first having the excess lymph fluid removed. A sleeve does not provide the compression and challenge to the lymphatic system that the wrapping does, thus, it is not an effective therapy for swelling. Once the excess fluid is massaged out of the limb a compression sleeve is able to be worn for cosmetic purposes usually, not to keep the limb reduced. 4) Manual Lymph Drain (MLD) to initiate removal of static lymph fluid and develop collateral lymphatic pathways. In summary, the therapy preference of CDP: skin care, MLD, compression wrapping, and exercise is the treatment modality of choice for LE. This project addresses primarily one part of the Health Belief Model—a Cue to Action—through specifically, the development of a “patient information brochure” to aid the individual at risk for secondary LE to self-monitor and self- care. Previous options, still used in the United States, include the sequential pneumatic pump, surgery, or simply prescribing use of a compression stocking—without first evacuating the limb of excess lymph fluid. These options are ofientimes, at worst, scientifically unsound, drastic, and at least, ineffective (Foldi, et al, 1989). Educating persons at risk of developing lymphedema about CDP offers Americans today the same successful outcome as other people are enjoying in other countries. ADULT LEARNING PRINCIPLES Knowles’ (1984) principles of the adult learner are pertinent and relevant to the development of a patient information brochure to address the problem of LB. Knowles’ principles of the adult learner states that: 1) The adult is self-directed and engages in independent learning as opposed to dependent learning. This “need to know” provides a rich field of possibilities for the 12 health care provider through the use of educational materials. 2) Adults have a self-concept of being responsible for their own lives. Health care professionals are able to facilitate this responsibility by providing educational materials that empower patients to take care of their bodies, understand the disease process, and learn health promotive techniques. 3) Each adult is a rich resource of accumulated experience. Each disease process must be customized to be applicable to the individuals particular living situation. Support groups address this assumption by bringing persons together with difl‘erent life stories and different strategies for healing with a similar problem. Using educational materials in a peer group setting provides diversity in problem solving. 4) Adults have a readiness to learn, especially if they perceive the information to be relevant to their ability to effectively cope and care for themselves and/or their families. Providing educational materials throughout the health-care experience allows the patient to have access to relevant information. Informational brochures, videos, lending libraries, etc. are all ways of inducing readiness to be pro-active in one’s own health care. 5) Adults are internally motivated to enhance their perceived quality of life. Educational materials can empower patients to keep growing and becoming more complex throughout their lives and especially throughout a “health crisis”. There are numerous implications in providing education materials, especially to prevent the nemesis of lymphedema. Based on Knowles’ principles, educational materials are part of the health care teams’ accountability with “informed consent”. This has an ethical implication which addresses “why” and “what” questions related to possible problems of limb swelling after surgery or radiation for cancer. Educating patients through teaching materials and techniques helps change behavior and promote optimal well-being. Educational materials can enhance a person’s sense of independence. As suggested in the HBM (Fig. 2), an educational brochure is a “cue-to-action” — a tool which describes specific actions the individual at risk of LE can 13 take to protect themselves from developing severe swelling in the involved limb. If LE has already occurred, the booklet offers suggestions to reduce the limb size with rationale for responsibly using diet, exercise, stress management, and medical intervention. LITERATURE REVIEW There is a paucity of information in the area of lymphedema prevention. Carter (1993) has studied extensively the psychosocial problems of women post-mastectomy. Two themes can be found from her research: 1) the women in her study wanted health care workers to be knowledgeable about LE and 2) the women who developed secondary LE found that living with LE was more distressing than the initial diagnosis of cancer. Studies can be found suggesting that if fewer nodes are taken during surgery there is lower incidence of secondary LE (Larson, Weinstein, Goldberg, Silver, Recht, Cady, Silen, & Harris, 1986) The number of nodes removed may not be as important as scarring from rough surgical handling or excessively damaging radiation therapy (Tsyb, Bardychev, Guseva, 1981; Kissin, Querci della Rovere, Easton, & Westbury, 1986). There are studies that validate the importance and relevance of patient education materials. In 1994 a study examined the effectiveness of video material and written material compared with the control group that received no educational material (Meade, McKinney, Bamas, 1994), The author studied 1100 colon cancer patients randomized in three groups and found no difference in short term knowledge gained between printed or video material and while both significantly increased knowledge the control group, who did not receive additional information, did not show an increase. Rice (1992) reported a New Hampshire Blue Cross/Blue Shield study that offered to reimburse physicians a reasonable amount for each patient viewing educational videos and materials for informed medical decision-making. The implications of the study suggest that educational materials increase self-care which decreases medical procedures and results in health insurance savings. 14 Harrison-Woermke and Graydon (1993) demonstrated the high informational needs of breast cancer patients undergoing radiation therapy. Educational materials were of benefit to the subjects at various points in their treatment continuum. Getting the diagnosis of a life threatening illness often times causes person’s to “shut down” in their ability to attend and retain information. Reinforcing important material regarding treatment options and possible sequelae is ethically responsible. From a perspective of the Health Belief Model, educational material is a structural variable and has a modifying effect on the perceived threat of a disease or illness. METHODS This brochure will serve as an educational tool to increase the client’s knowledge about her/his body. It will briefly explain the anatomy and pathophysiology of LB and the management therapy of CDP. Precautions and guidelines for a preventive lifestyle will also be offered. It will be printed on high quality paper with graphics that are artistically clear and pleasing. Color illustrations will enhance the aesthetic appearance. The language will be appropriate for junior high comprehension level. Some medical terminology will be included to provide knowledge for the patient about the body’s anatomy and physiology as it relates to the nemesis of lymphedema. The target population for this brochure are persons who have undergone treatment for cancer. Lymphedema education is a segment, albeit a new segment, of the larger clinical plan or pathway in cancer treatment. Distributing the brochure in primary care facilities will increase public awareness about lymphedema. Speaking to health care practitioner groups, cancer nursing groups, and cancer support groups, will also be an avenue for disseminating the brochure. The National Lymphedema Network is a non- profit organization dedicated to the dissemination of information and networking. Making the patient information booklet 15 available to them for national distribution would make the information accessible to thousands. Lymphedema can be delayed for months and even years following cancer treatment. An informational brochure can heighten awareness as part of a multifocal preventive framework intended to increase quality of life long after the treatment for , cancer has passed. DISTRIBUTION The brochure will be distributed through the local American Cancer Society network as well as the area Medical Society. The American Cancer Society has an established resource center and has “voiced” enthusiasm to make the information available. As a member in good standing of the National Oncology Nurses Society as well as the local chapter of the ONS, introduction will be done by the author via the Southwestern Michigan Chapter monthly meeting. Brochures will also be made available in the waiting rooms of the local hospitals, oncology floors, and local physicians private offices. EVALUATION Once the brochure is produced it will be evaluated through feedback of local healthcare practitioners—both primary care and specialists and at a number of support groups for persons with LE. Open discussion will be taken regarding the brochure’s clarity and informational content. The accuracy of the contents and the graphics will be evaluated. Requesting that patients and practitioners alike respond to the content of the brochure will provide feedback that ensures the information be relevant, pertinent, and able to act as a “living resource”. An evaluation form will be distributed with the booklet asking that feedback be given in a timely manner. The support groups meet monthly. Participants will be given the booklet with instructions and evaluation forms and requested 16 to return the feedback forms the following month. Health care practitioners will be addressed personally and given approximately two weeks time to study the booklet and write their impressions. IMPLICATIONS FOR ADVANCED NURSING PRACTICE IN PRIMARY CARE Educating persons about the potential risk of LE helps patients gain a sense of independence in their own self-care. This may enhance their sense of emotional safety and also allow them to be more physically safe in ways they choose to care for their involved limb. The preventive measures involved in the care of LB allow persons to enter into a f" proactive lifestyle by making decisions regarding exercise, diet, and stress management. A t: poorly informed patient is an “at risk” patient. The advanced practice nurse’s role includes the education of the greater community audience. A consultative role has been established to help hospital personnel, health clinic centers, physicians, and support group members understand the nemesis of lymphedema and how to encourage a lifestyle modification program for persons having to live with LE. Providing educational tools and time to teach is a reimbursable service. Documenting information regarding lymphedema satisfies the Nurse Practice Act and the “Patient’s Bill of Rights”. This acknowledges the provider’s legal implication to educate. There are implications for future research. Longitudinal studies need to be done to measure cost effectiveness of lymphedema education. Data collection needs to develop to illustrate effectiveness outcomes for individuals at risk of LB. Studies need to be conducted to determine the best time/best technique for information delivery. There is an implication to study the impact of educational tools on psychosocial distress and perceived quality of life by people with secondary LE as a sequela to cancer treatment. Advanced practice nurses are advocates for consumers in the healthcare industry. Supporting patients to attain the highest outcome with the least negative consequence is a 17 challenge in the current arena of cancer treatment. Health care professionals in primary care, cancer care, and health education/rehabilitation settings, must continue to strive for disease free survival combined with a reasonable quality of life. Secondary LE is a life long pathological condition. Its onset can be subtle and unpredictable. Persons who have survived the treatment options for cancer are entitled to live full and productive years once [the cancer is cured. A patient information booklet is an effective teaching strategy to prevent or effectively manage secondary LE. 18 BIBLIOGRAPHY Becker, M. (1974). Health belief model and personal health behavior. Thorofare, New Jersey: Chas. B. Slack, inc. Becker, M., Drachman, R., and Kirscht, J. (1974). A new approach to explaining sick-role behavior in low income populations. American Journal of Public Health, 64(3 ), 205-216. Brennan, M. (1992). Lymphedema following the surgical treatment of breast cancer: a review of pathophysiology and treatment. Journal of Pain and Symptom Management, 7(2), 1 10-1 16. Britton, R., and Nelson, P. (1962). Causes and treatment of postmastectomy lymphedema of the arm. Journal of the American Medical Association. 180(2), 95-102. Carter, B. (1993). Long-term survivors of breast cancer: a qualitative descriptive study. Cancer Nursing, 16(5), 354-361. Dennis, B. (1993). Acquired lymphedema: a chart review of nine women’s responses to intervention. American Journal of Occupational Therapy. 47(10),891-899. Fink, R. “Shapiro S., Roester, R (19720. Impact of efforts to increase participation in repetitive screenings for early breast cancer detection American Journal of Public Hea_lth, 62, 328- 336. Foldi, E., Foldi, M., Clodius, L. (1989). The lymphedema chaos: a lancet. Annals of Plastic Surge_ry, 22(6), 505-515. Granda, C. (1994). Nursing management of patients with lymphedema associated with breast cancer therapy. Cancer Nursing, 17(3), 229-235. Harrison-Woermke, D., and Graydon, J. (1993). Perceived informational needs of breast cancer patients receiving radiation therapy after excisionalbiopsy and axillary node dissection. Cancer Nursing, 16(6), 449-455. Kissin, M., Querci della Rovere, Easton, D., Westbury, G. (1986). Risk of lymphedema following breast cancer. BritishfiJournal of Surggy, 73(7), 580-584. 482m?» ti Ont“ l9 Knowles, M. (1988). The Adult Learner: A Neglected Species. Houston: Gulf Publishing House. Larson, D., Weinstein, D., Goldberg, 1., Silver, B., Recht, A., Cady, B., Silen, W, Harris, J. (1986). Edema of the arm as a fimction of the extent of axillary surgery in patients with stage I—II carcinoma of the breast treated with primary radiotherapy. Journal of Radiation Oncolgy~Biolog~Physics 12(9), 1575-1582. McCorkle, R. (1995). Living with Lymphedema. Innovations in Breast Cancer Care, 1(1), 22-23. Meade, C., McKinney, P., Bamas, G. (1994). Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. American Journal of Public Heam, 84(1), 119-12]. Miller, L. (1994). Lymphedema: unlocking the doors to successful treatment. Innovations in Oncology Nursing, 10(3), 53, 58-62. Mirolo, B., Bunce, I., Chapman, M., Olsen, T., Eliadis, P., Hennessy, J ., Ward, L., Jones, L.(1995). Psychosocial benefits of postmastectomy lymphedema therapy. Cancer Nursing, 18(3), 197-205. Olszewski, W. (1985). Peripheral lymph: formation and immune function. Boca Raton, Florida: CRC Press, inc. Pender, N. (1987). Exercise and physical fitness. In I-_I_e.althJ_)_romotion in nursing practice, (p. 287). Norwalk, Conn: Appleton and Lange. Rice, B. (1992). Educate your patients without taking more time. Medical Economics, Oct. 5, 92-105. Simon, M., and Cody, R. (1992). Cellulitis after axillary lymph node dissection for carcinoma of the breast. The American Journal of Medicine. 93, 543-548. Tobin, M., Lacey, H., Meyer, L., and Mortimer, P. (1993). The psychological morbidity of breast cancer-related arm swelling. Cancer, 72(11), 3248-3252. Tsyb, A. F., Bardychev, M. S., Guseva, L. I. (1981). Secondary limb edemas following irradiation. Lmrphology 14, 127-132. Whitman, M. and McDaniel, R. (1993). Preventing lymphedema: an unwelcome sequel to breast cancer. Nursing 93, December, 36-39. Wittlinger, H. and G. (1982). Introduction to Dr. Vodder’s manual lymph drainage volume 1: bafiic course. Heidelberg: Haug Publishers. Pocket: M; l hoatle’f patient Guidelines to prevention and Management After Surgery or Radiation Treatment I f0 I»A COHCQI’ ;A program for to Reduce I ' M IIIIIIIIIIIIIIIIIIII IlrlyrrIIgljirlrlrllzrryallryyII l .