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Review Article • Acta Paul Enferm 37 • 2024 • https://doi.org/10.37689/acta-ape/2024AR00014322   copy

Ineffective self-management of lymphedema in mastectomized women: concept analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To analyze the concept of “ineffective self-management of lymphedema” in mastectomized women.

Methods

This is an analysis of the concept proposed by Walker and Avant, operationalized through an integrative literature review, organized into eight stages, and based on the following guiding questions: What is the definition of ineffective self-management in mastectomized women? What are the antecedents, attributes, and consequences of ineffective self-management in mastectomized women? How has ineffective self-management of lymphedema been defined in the context of women who have undergone mastectomy? The search for articles was carried out in five electronic databases, with no date limit, from July 2022 to February 2023.

Results

Antecedents (30) and consequents (19) were identified. Among them, the most frequent were the following, respectively: lack of family and/or social support and decreased quality of life. The most frequently identified defining attributes were the following: edema, swelling in the arm, feeling of heaviness in the limb, pain, numbness, and reduced function of the limb. Model and contrary cases were also designed to help decide on the use of the concept.

Conclusion

The concepts resulting from the analysis contribute to clarifying the terms and development of language in nursing, and should be validated by judges and clinical practice for better application in clinical oncology.

Lymphedema; Mastectomy; Breast neoplasms; Self care; Self-management

Resumo

Objetivo

Analisar o conceito de “autogestão ineficaz do linfedema” em mulheres mastectomizadas.

Métodos

Trata-se de uma análise do conceito proposto por Walker e Avant operacionalizada por meio de uma revisão integrativa da literatura, organizada em oito etapas e baseada nas seguintes questões norteadoras: Qual é a definição de autogestão ineficaz em mulheres mastectomizadas? Quais os antecedentes, atributos e consequências da autogestão ineficaz em mulheres mastectomizadas? Como a autogestão ineficaz de linfedema tem sido definida no contexto de mulheres que passaram por mastectomia? A busca de artigos foi realizada em cinco bases de dados eletrônicas, sem limite de data, no período de julho de 2022 a fevereiro de 2023.

Resultados

Foram identificados 30 antecedentes e 19 consequentes; os mais frequentes entre eles foram respectivamente os seguintes: falta de apoio familiar/social e diminuição da qualidade de vida. Os atributos definidores mais frequentemente identificados foram os seguintes: edema, inchaço no braço, sensação de peso no membro, dor, dormência e diminuição da função do membro. Foram ainda elaborados os casos modelo e contrário para auxiliar na decisão sobre o uso do conceito.

Conclusão

Os conceitos resultantes da análise contribuem para clarificar os termos e o desenvolvimento da linguagem na enfermagem, devendo ser validados por juízes e prática clínica para melhor aplicação na oncologia clínica.

Linfedema; Mastectomia; Neoplasias da mama; Autocuidado; Autogestão

Resumen

Objetivo

Analizar el concepto de “autogestión ineficaz de linfedema” en mujeres mastectomizadas.

Métodos

Se trata de un análisis del concepto propuesto por Walker y Avant, realizado mediante una revisión integradora de la literatura, organizado en ocho etapas y basado en las siguientes preguntas orientadoras: ¿Cuál es la definición de autogestión ineficaz en mujeres mastectomizadas? ¿Cuáles son los antecedentes, atributos y consecuencias de la autogestión ineficaz en mujeres mastectomizadas? ¿Cómo se define la autogestión ineficaz de linfedema en el contexto de mujeres que pasaron por una mastectomía? La búsqueda de artículos fue realizada en cinco bases de datos electrónicas, sin límite de fecha, en el período de julio de 2022 a febrero de 2023.

Resultados

Se identificaron 30 antecedentes y 19 consecuentes. El antecedente más frecuente fue falta de apoyo familiar/social y el consecuente, reducción de la calidad de vida. Los atributos definidores identificados más frecuentemente fueron los siguientes: edema, hinchazón en el brazo, sensación de peso en el miembro, dolor, adormecimiento y reducción de la función del miembro. Además, se elaboraron los casos modelo y contrarios para ayudar en la decisión sobre el uso del concepto.

Conclusión

Los conceptos resultantes del análisis contribuyen a clarificar los términos y el desarrollo del lenguaje en enfermería y deben ser validados por jueces y práctica clínica para una mejor aplicación en la oncología clínica.

Linfedema; Mastectomía; Neoplasias de la mama; Autocuidado; Automanejo

Introduction

Post-mastectomy lymphedema is the most frequent occurrence (10-60%) related to the treatment of breast cancer (CA), depending on the parameter used. It can greatly affect women’s quality of life in biopsychosocial aspects such as self-esteem and health-related costs, leading to feelings of weakness, fear, and anxiety.(11. Kalemikerakis I, Evaggelakou A, Kavga A, Vastardi M, Konstantinidis T, Govina O. Diagnosis, treatment and quality of life in patients with cancer-related lymphedema. J BUON. 2021;26(5):1735–41. Review.

2. Quirion E. Recognizing and treating upper extremity lymphedema in postmastectomy/lumpectomy patients: A guide for primary care providers. J Am Acad Nurse Pract. 2010;22(9):450–9. Review.-33. Arinaga Y, Sato F, Piller N, Kakamu T, Kikuchi K, Ohtake T, et al. A 10 minute self-care program may reduce breast cancer-related lymphedema: a six-month prospective longitudinal comparative study. Lymphology. 2016;49(2):93–106.)

The study focus on women with lymphedema who survived breast CA was justified because this sequela is a chronic condition that continually affects the lives of these women. They are the object of self-care planning in the stages involving nursing, with relevance to clinical practice.44. Paiva AC, Elias EA, Souza ÍE, Moreira MC, Melo MC, Amorim TV. Cuidado de enfermagem na perspectiva do mundo da vida da mulher-que-vivencia-linfedema-decorrente-do-tratamento-de-câncer-de-mama. Esc Anna Nery. 2020;24(2):e20190176.

“Ineffective self-management of lymphedema” is a nursing diagnosis defined by NANDA International 2021-2023 (NANDA-I®) as: “unsatisfactory management of symptoms and treatment regimen, with physical, psychosocial, and spiritual consequences, including change in inherent lifestyles, leading to living with edema related to obstruction or disorder of lymph nodes or lymphatic vessels”. The above diagnosis was approved (2020) and included in NANDA-I®, in the activity and/or rest domain, with level of evidence 2.1 referring to the development of the conceptual framework that will support the interpretations of the constituent elements of nursing diagnosis (ND). Conducting the first stage of validation studies and presenting a substantial body of knowledge is necessary to increase the level of evidence and support the diagnosis.(88. Herdman TH, Kamitsuru S, Lopes CT. NANDA International Nursing Diagnoses: definitions and classification 2021–2023. 12th Edition. New York: Thieme; 2021. 590 p.)

Although ineffective self-management is present in another diagnosis in NANDA International and in recent studies,(99. da Silva RC, Gondim MC, Cavalcante AM, Bachion MM, da Silva VM, de Oliveira Lopes MV. Ineffective health management: a systematic review and meta-analysis of related factors. J Nurs Scholarsh. 2022;54(3):376-87.) lymphedema can often be diagnosed as erysipelas or cellulitis, even in mastectomized women. This can lead to different treatments that do not always involve the participation of patients, especially as agents of self-care.(1010. Rockson SG, Keeley V, Kilbreath S, Szuba A, Towers A. Cancer-associated secondary lymphoedema. Nat Rev Dis Prim. 2019;5(1):22. Review.) Thus, identifying gaps in elements related to ineffective self-management of lymphedema absent in NANDA-I® will make the topic more understandable in clinical practice. This can delimit and elucidate the field of nursing practice, as different elements can interfere with its occurrence in this population.

To improve the ND under study in this scenario, investigating the concepts used in the literature, and verifying the defining attributes and their definitions are necessary.(1111. Walker L , Avant K . Stages for Theory Construction in Nursing. 5 th ed. Pearson; 2014. 426 p.) Therefore, the present study aimed to analyze the concept of ineffective self-management of lymphedema in mastectomized women.

Methods

The concept analysis model proposed by Walker and Avant was adopted to develop this stage, being operationalized based on the integrative literature review and organized into eight stages: (1) concept selection, (2) determination of the objectives of conceptual analysis, (3) identification of possible uses of the concept, (4) determination of critical attributes, (5) construction of a model case, (6) development of other (opposite, invented, or illegitimate) cases, (7) identification of the antecedents and consequences of the concept, and (8) definition of empirical references for the defining attributes.(1111. Walker L , Avant K . Stages for Theory Construction in Nursing. 5 th ed. Pearson; 2014. 426 p.)

Initially, the following guiding questions were formulated: What is the definition of ineffective self-management in mastectomized women? What are the antecedents, attributes, and consequences of ineffective self-management in mastectomized women? How has ineffective self-management of lymphedema been defined in the context of women who have undergone mastectomy? To better direct search strategies, these questions were directed to articles identified in a specific population of mastectomized women, according to the acronym PCC which means: P (population): women; C (concept): self-management of lymphedema, and C (context): mastectomized women. Articles without date limit were selected from five databases: Virtual Health Library, PubMed, Web of Science, CINAHL, and SCOPUS. The search in the databases occurred from July to August 2022, being reviewed in February 2023 to include articles that could have been published in that time interval. The search strategy followed the criteria of each database combined with the Boolean operators “AND” and “OR” and the following terms: axillary lymphedema, breast cancer, breast removal, lymphedema, lymphoedema, mastectomy, extended radical mastectomies, nursing, breast removal, self-management, and self-care. The search strategies in the databases are shown in Table 1.

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Table 1
Database search strategies

The inclusion criteria were as follows: address the topic of self-management and/or self-care of lymphedema in women with mastectomy, have been published in Portuguese, English, or Spanish, and answer the guiding questions of this study. Previous notes, reviews, projects, protocols, ongoing research, and letters to editors were excluded.

After identifying the articles, they were exported to the systematic review manager Rayyan - Intelligent Systematic Review. Independent and blinded reading of titles and abstracts was carried out by two researchers to identify articles that met the inclusion criteria. Discordant cases were resolved by a third researcher. The selected articles were read in full, including the title and abstract. Articles that were not available electronically were acquired by direct request to the author. In each article, the, consequences, and attributes were identified and grouped following an approach guided by the guiding questions.

Results

The articles were characterized, and the results were presented according to the steps of the proposed concept analysis, except for the description of the empirical references as they did not contemplate the proposed objective. Figure 1 follows the scheme recommended by the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).(1212. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372. Review.) A total of 1200 articles were identified; 277 of them were selected and 43 articles were the final sample.

Figure 1
Flowchart of the search and selection stages of articles (adapted from the PRISMA model)

Table 2 shows the characteristics of the 43 articles selected according to the inclusion criteria that guided this review: year, country, authors, study title, journal, design, and level of evidence (LE) according to the Melnik and Fineout-Overholt classification.(1313. Melnik B, Fineout-Overholt E. Evidence-based practice in nursing and health: a guide to best practice. Philadelphia: Wolters Kluwer; Lippincott Williams & Wilkins Health; 2011)

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Table 2
Studies included in the literature review according to the information extracted from the articles (n=43)

The highest percentage of articles (25.6%) was published in the last five years (2019-2023) predominantly in English. Nurses (56.0%), psychologists (14.6%), medical doctors (9.7%), as well as occupational therapists, physiotherapists, and professionals in related areas (4.9%) were the authors of the studies. Among the studies evaluated, cross-sectional (20.9%) and randomized controlled studies (14.0%) were the most frequent.

From the studies analyzed, the concept of ineffective self-management was applied in 43 studies that dealt with lymphedema in women with mastectomies. However, none of these articles evidenced a clear and defined concept about the nursing diagnosis under study. The lymphedema self-management activities listed by the studies mainly included: know the factors and risk signs for developing lymphedema, monitoring the affected limb for characteristic signs of lymphedema, prevention of trauma to the affected extremity and the risk of infection, prevention and maintenance of skin integrity, maintaining adequate weight and carrying out regular physical activity. Such actions correspond to acceptance and knowledge of the disease, perception and recognition of risk factors and triggers of worsening, and caring attitudes. The defining attributes correspond to the content of the concept analysis.(1111. Walker L , Avant K . Stages for Theory Construction in Nursing. 5 th ed. Pearson; 2014. 426 p.) The 31 identified attributes are shown in Chart 3. The most frequent attributes were “edema and/or swelling” in the limb (mentioned in ten articles) and “feeling of heaviness in the arm” (cited in six articles).

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Chart 3
Attributes and frequency of ineffective lymphedema self-management identified in the articles

From the analysis of the selected studies, 30 antecedents were identified and distributed into three categories: patient, access to information and educational practices, and treatment adherence (Chart 4).

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Chart 4
Antecedents and frequency of ineffective self-management of lymphedema identified in the literature

A total of 19 consequences of the concept of “ineffective self-management of lymphedema” were identified in the articles (Chart 5). To identify the consequences, the following question was asked: What are the events resulting from ineffective self-management of lymphedema in mastectomized women?

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Chart 5
Distribution of consequences of ineffective self-management of lymphedema

Contrary case case of self-management of lymphedema in mastectomized women

Mrs. Angélica (58 years old, widow, illiterate) lives with her daughter, with an income of one minimum wage from retirement. She was diagnosed with cancer in her right breast in 2020; she underwent a total mastectomy and had axillary dissection; a total of 22 lymph nodes were removed and she received 36 sessions of radiotherapy. She reported that she avoids using her right arm for daily activities such as cooking or washing dishes, but she did not perform daily skin care or wear compression sleeves. She was unable to maintain her physical exercise and lymphatic drainage routine. Eight months after the surgery, her arm started to swell but she did not know why because she was not advised about this fact. Pain appeared in the right scapular region, limiting extension and flexion; numbness with a feeling of heaviness. Loss of movement in her arm, with progressive worsening of pain, led her to use frequent analgesic medication. She reported worsening pain during manual lymphatic drainage. The daughter reported that her mother does not accept her health problem. The mother has difficulty in monitoring with a multidisciplinary team because she lives on the outskirts of the city.

Model case of self-management of lymphedema in mastectomized women

Mrs. Ana (59 years old, married) lives with her husband and two daughters, with a family income of six minimum wages. She was diagnosed with breast cancer in 2019. She underwent a mastectomy and axillary dissection with removal of the nodules and underwent chemotherapy sessions. A year after the mastectomy, her arm began to become edematous, as the blouses were tight on only one side. She was diagnosed with lymphedema. She reported that she followed the guidelines given by the multidisciplinary team at the oncology center near where she lives. She maintains a balanced diet to control her weight and exercises three times a week. She always keeps her arms clean and dry by applying body moisturizer, sunscreen, and repellent. She performs manual lymphatic drainage daily, and maintains the use of compression clothing for strenuous activities and air travel, in addition to avoiding places of extreme cold or heat. Whenever she goes to the health service, she avoids checking pressure or puncturing in her left arm. Her family does all the domestic work, encouraging her in her routine care. She reported that their help has made a difference in her treatment over the years, preventing her from developing further complications with lymphedema in her arm so far, which is a constant fear.

Discussion

When analyzing the articles, the countries of publication were different. Those from North America and Europe stood out, being related to the highest incidence of breast CA and prevalence of lymphedema.(5454. Deveci Z, Karayurt Ö, Bilik O, Eyigör S. Development of the breast cancer related lymphedema self-care scale. Clin Nurs Res. 2023;32(1):221–32.,5555. Ostby PL, Armer JM, Smith K, Stewart BR. Patient perceptions of barriers to self-management of breast cancer–related lymphedema. West J Nurs Res. 2018;40(12):1800–17.)

After 2012, an increasing number of studies developed by nurses was observed, which influenced the development of our study. Furthermore, the presence of studies developed by professionals (such as doctors, physiotherapists, and psychologists) points to a comprehensive understanding of the complex management that involves lymphedema and its multidisciplinary nature. E.g., physiotherapists develop studies related to the use of new techniques for managing and measuring lymphedema; they contribute to the early detection of indicators that lead to ineffective self-management, also contributing to educational practices for mastectomized women.(4141. Rafn BS, McNeely ML, Camp PG, Midtgaard J, Campbell KL. Self-measured arm circumference in women with breast cancer is reliable and valid. Phys Ther. 2019;99(2):240–53.)

In this group of people, the aspects involving lymphedema show the extent to which the phenomenon can manifest itself, as evidenced in the different categories presented in the antecedents. When there is more than one antecedent or related factor interacting with people, the human response can show different levels of severity, from the exclusive presence of local edema (and decreased mobility of the limb) to the impact on quality of life and social relations. Different levels of severity of ineffective lymphedema self-management can also trigger other human responses.(5656. de Oliveira Lopes MV, da Silva VM, Herdman TH. Causation and Validation of Nursing Diagnoses: A Middle Range Theory. Int J Nurs Knowl. 2017;28(1):53–9.)

Given the importance of multidisciplinary management in the clinical practice of nurses for better quality of life of mastectomized women, having the contribution of different professional perspectives and the exchange of knowledge between their areas is essential for the self-care and rehabilitation of these patients. However, few studies have deepened into this topic.

Concerning the defining attributes most explored by the authors in the articles analyzed, edema and/or swelling of the arm, sensation of heaviness, pain, and numbness were recurrent. “Arm edema and/or swelling” is related to the accumulation of extracellular fluid as a result of damage to the lymphatic system related to breast cancer treatment.(1010. Rockson SG, Keeley V, Kilbreath S, Szuba A, Towers A. Cancer-associated secondary lymphoedema. Nat Rev Dis Prim. 2019;5(1):22. Review.)This leads to a decrease in the distensibility of the tissue around the joints and an increase in the weight of the extremities, causing a feeling of heaviness, numbness, and decreased function of the affected limb.(5757. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. J Natl Cancer Inst. 2001;93(2):96–111. Review.)

Attribution of ineffective self-management of lymphedema to the presence of edema and ‘aesthetic and functional’ aspects of the affected limb has also been observed, and factors related to self-management have not been adequately explored. This may be related to the subjectivity of the clinical assessment to which mastectomized women are subjected, as the presentation of lymphedema as a sequelae of oncological treatment is expected, causing confusion of concepts, making the investigation and identification of the attributes analyzed more complex.

Pain is a symptom defined as an unpleasant sensory and emotional experience, associated with real or potential tissue damage, of sudden or slow onset and mild to severe intensity, with an anticipated or predictable end.(88. Herdman TH, Kamitsuru S, Lopes CT. NANDA International Nursing Diagnoses: definitions and classification 2021–2023. 12th Edition. New York: Thieme; 2021. 590 p.,5858. Raja S, Carr D, Cohen M, Finnerup N, Flor H, Gibson S. The Revised IASP definition of pain: concepts, challenges, and compromises. Pain. 2021;161(9):1-16.)

A study by Fabro et al. highlighted that pain (as a neuropathic condition) had an incidence of 52.9% six months after surgical treatment for breast cancer. Pain in the shoulder and/or thoracoscapular region resulting from surgical treatment of breast cancer was observed in 27.2% of patients; younger women (younger than 40 years old) and those who underwent axillary lymphadenectomy (more than 15 lymph nodes removed) were at greater risk of developing pain syndrome.(5959. Alves Nogueira Fabro E, Bergmann A, do Amaral E Silva B, Padula Ribeiro AC, de Souza Abrahão K, da Costa Leite Ferreira MG, et al. Post-mastectomy pain syndrome: incidence and risks. Breast. 2012;21(3):321-5.)

In patients who present such attributes, early intervention by the multidisciplinary team with self-management strategies can reduce the risk of progression of lymphedema related to breast CA. Nurses can incorporate such strategies into these women’s daily lives to reverse the stages of lymphedema, in addition to making them see themselves as agents of their self-care.

The attributes support nurses’ decisions to identify ineffective self-management of lymphedema, contributing to planning effective actions based on patient training and engagement concerning the phenomenon. Although the patient in the fictitious case was also diagnosed with lymphedema after breast cancer, defining attributes and antecedents are not perceived in the context of the model case, discouraging nurses from developing actions focusing on ineffective self-management.

As for the antecedents, those attributed to the patients are the ones that stand out the most. However, those related to adherence to self-care, as well as the difficulty in adhering to self-care guidelines using accessible technologies and/or devices and techniques (bandages, compression garments, pneumatic compression, manual lymphatic drainage, physical exercises, and bioimpedance) were the most frequent. Specialized accessible and cost-effective interventions for mastectomized women with lymphedema need to be further explored. Such interventions may present a high risk of complications, in addition to the changes in habits and routines already required to achieve and maintain successful treatment results.(2222. Ridner SH, Dietrich MS, Kidd N. Breast cancer treatment-related lymphedema self-care: Education, practices, symptoms, and quality of life. Support Care Cancer. 2011;19(5):631-7.,2424. Assis MR, Maraglia PH, Brandão MA, Peixoto MA. Metacognition as an educational technology in self-care learning: the case of prevention of post-surgical lymphedema of breast cancer. Esc Anna Nery. 2018;22(3):e20170440.,2828. Koelmeyer LA, Sherman KA, Boyages J, Dean CM. Understanding home monitoring and self-management in breast cancer-related lymphoedema: a qualitative study. J Lymphoedema. 2021;16(1):54-61.)

Studies show that less than a third of women adhere to self-care practices.(3131. Deveci Z, Karayurt Ö, Eyigör S. Self-care practices, patient education in women with breast cancer-related lymphedema. Turkish J Phys Med Rehabil. 2021;67(2):187–95.,4646. Alcorso J, Sherman K, Koelmeyer L, Mackie H, Boyages J, Sherman KA. Psychosocial factors associated with adherence for self-management behaviors in women with breast cancer-related lymphedema. Support Care Cancer. 2016;24(1):139–46.)This lack of adherence may be related to a lack of knowledge about self-care. In the articles analyzed, this is a significant indicator. The multiple barriers to self-care reinforce the multidisciplinary approach focused on education and self-monitoring to improve the quality of life of this population.(3535. Ridner S, Rhoten B, Radina M, Adair M, Bush-Foster S, Sinclair V, et al. Breast cancer survivors’ perspectives of critical lymphedema self-care support needs. Support Care Cancer. 2016;24(6):2743–50.)

Women need to take responsibility for their self-care, incorporating it permanently into their routine. This requires reinforcement in the teaching-learning process and awareness. Technological devices and improved techniques are needed.(2424. Assis MR, Maraglia PH, Brandão MA, Peixoto MA. Metacognition as an educational technology in self-care learning: the case of prevention of post-surgical lymphedema of breast cancer. Esc Anna Nery. 2018;22(3):e20170440.)

In addition to teaching and awareness about the importance of lymphedema, it must be considered that cognitive and affective changes in a situation of health threat can influence the lack of adherence. Therefore, they must also be observed by professionals.(4343. Sherman KA, Miller SM, Roussi P, Taylor A. Factors predicting adherence to risk management behaviors of women at increased risk for developing lymphedema. Support Care Cancer. 2015;23(1):61–9.) On the other hand, a study showed that participants understand their chronic problems, but realize that the health team does not have the necessary knowledge when diagnosing lymphedema. This leads to a lack of expectation about the treatment and what it will provide, affecting the management of the problem.(4747. Karlsson K, Biguet G, Johansson K, Nilsson-Wikmar L. Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective. Scand J Caring Sci. 2015;29(1):110–7.)

In this context, nursing interventions aimed at preventive behavior and long-term monitoring help to prevent lymphedema when supported by home visits. Furthermore, they are considered cost-effective, reducing the financial burden on both the patient and the healthcare system.(1616. Cal A, Bahar Z, Gorken I. Effects of Health Belief Model based nursing interventions offered at home visits on lymphedema prevention in women with breast cancer: a randomised controlled trial. J Clin Nurs. 2020;29(13–14):2521–34.)

Consequences are events that occur as a result after the concept occurs; they cannot be considered defining attributes of the concept under analysis.(1111. Walker L , Avant K . Stages for Theory Construction in Nursing. 5 th ed. Pearson; 2014. 426 p.) Thus, it was observed that the pain component (cited in 14.0% of articles) appears as a consequence but also appears as a defining attribute. The NANDA-I® taxonomy does not present the pain component as a defining characteristic.(88. Herdman TH, Kamitsuru S, Lopes CT. NANDA International Nursing Diagnoses: definitions and classification 2021–2023. 12th Edition. New York: Thieme; 2021. 590 p.)

The defining characteristics are dynamic and changeable; they contribute to preparing the ND by nurses, assisting in the planning of nursing interventions. Considering the direction of Walker and Avant,(1111. Walker L , Avant K . Stages for Theory Construction in Nursing. 5 th ed. Pearson; 2014. 426 p.)we can state that pain is a consequence of ineffective self-management of lymphedema, being disregarded as a defining attribute. However, the clinical consequences are an exacerbation of the attributes associated with exposure to clinical antecedents; a greater degree of impairment can be observed in the consequence depending on the intensity of this exposure.(5555. Ostby PL, Armer JM, Smith K, Stewart BR. Patient perceptions of barriers to self-management of breast cancer–related lymphedema. West J Nurs Res. 2018;40(12):1800–17.)

The three most frequent consequences were the following: decrease in life quality (20.9%), interference with daily and work activities {recomendo coerência no arredondamento de casas decimais; lembrando que há ~10 valores de porcentagem expressos com uma casa decimal em todo o manuscrito} (16.27 16.3 %), and psychological distress (13.95 14,0 %).

The greater the swelling of the arm or hand, the greater the limitations observed in women with different degrees of lymphedema. The difficulties faced in simple activities of daily living, such as cleaning, bathing, and eating, are even greater. These difficulties result in their inability to take care of themselves.(2020. Swenson KK, Nissen MJ, Leach JW, Post-White J. Case-control study to evaluate predictors of lymphedema after breast cancer surgery. Oncol Nurs Forum. 2009;36(2):185–93.,4040. Cansız G, Arıkan Dönmez A, Kapucu S, Borman P. The effect of a self-management lymphedema education program on lymphedema, lymphedema-related symptoms, patient compliance, daily living activities and patient activation in patients with breast cancer-related lymphedema: a quasi-experimental study. Eur J Oncol Nurs. 2022;56:102081.)

The consequent “decrease in life quality” was pointed out by breast cancer survivors. They highlighted elements that help achieve a better quality of life, such as involvement in treatment decisions and individualized support and advice for patients.(4747. Karlsson K, Biguet G, Johansson K, Nilsson-Wikmar L. Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective. Scand J Caring Sci. 2015;29(1):110–7.)

Psychological suffering is related to emotional disorders as daily disorders linked to lymphedema impact the lives of mastectomized women. The change in body image acts as a visible reminder of cancer and treatment, adding to patient reports of physical symptoms often used to assess distress levels.(3636. Jeffs E, Ream E, Shewbridge A, Cowan-Dickie S, Crawshaw D, Huit M, et al. Exploring patient perception of success and benefit in self-management of breast cancer-related arm lymphoedema. Eur J Oncol Nurs. 2015;20:173–83.)A study performed in Australian clinics showed an inversely proportional relationship between levels of distress and degrees of adherence to lymphedema self-management, reinforcing that psychological distress is a consequence of ineffective self-management of lymphedema.(4646. Alcorso J, Sherman K, Koelmeyer L, Mackie H, Boyages J, Sherman KA. Psychosocial factors associated with adherence for self-management behaviors in women with breast cancer-related lymphedema. Support Care Cancer. 2016;24(1):139–46.)

The presence of discomfort and fear related to lymphedema negatively affects women from a psychosocial point of view, resulting in psychological and body image disorders, reflecting on life quality. Therefore, clarifying the treatments that the health system can offer and involving cure expectations and functional impairments that can impact daily life is important.(2424. Assis MR, Maraglia PH, Brandão MA, Peixoto MA. Metacognition as an educational technology in self-care learning: the case of prevention of post-surgical lymphedema of breast cancer. Esc Anna Nery. 2018;22(3):e20170440.,4343. Sherman KA, Miller SM, Roussi P, Taylor A. Factors predicting adherence to risk management behaviors of women at increased risk for developing lymphedema. Support Care Cancer. 2015;23(1):61–9.,4545. Fu MR. Breast cancer survivors’ intentions of managing lymphedema. Cancer Nurs. 2006;28(6):446–57.,4747. Karlsson K, Biguet G, Johansson K, Nilsson-Wikmar L. Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective. Scand J Caring Sci. 2015;29(1):110–7.)

Conclusion

This concept analysis allows identifying the fundamental elements to understand the concept of ineffective self-management of lymphedema. This was achieved by identifying defining attributes, antecedents, consequences, model and contrary cases, thus contributing to clarifying this nursing diagnosis. Nursing diagnoses with lower levels of evidence are generally not incorporated into the nursing process, as their elements do not reflect clinical practice nor contribute to identifying effective strategies and managing the causers of ineffective self-management of lymphedema. The described and identified elements that resulted from this conceptual analysis require validation by judges and clinical application.

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Edited by

Associate Editor (Peer review process): Camila Takao Lopes (https://orcid.org/0000-0002-6243-6497) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Publication Dates

  • Publication in this collection
    04 Mar 2024
  • Date of issue
    2024

History

  • Received
    7 June 2023
  • Accepted
    30 Aug 2023
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