Pre‐procedure

ActionRationale

1. 1.Show
   Explain and discuss the proposed procedure with the patient.
   To ensure that the patient understands the procedure and gives their valid consent (NMC [202], C).
2. 2.Show
   Sit the patient in a chair with their arms extended in front and resting on the back of a chair. The arms should be as close to an angle of 90° to the body as possible.
   To ensure the arms are supported and accessible at a standard height. Changing the angle of the arms to the body will result in changes in the measurements. E
3. 3.Show
   If only one arm is swollen, start with the unaffected arm.
   To establish the normal limb as a control (Williams and Whitaker [286], E).

Procedure

1. 4.Show
   Measure the distance from the tip of the middle finger to the wrist. Mark the wrist, allowing at least 2 cm above the ulnar styloid, and note down the distance.
   To establish and clearly record a reproducible fixed starting point for all subsequent measurements (Lymphoedema Framework [153], E).
   Note: The marks represent a point midway through each cylinder segment, they do not represent the base of the cylinder, therefore at least half the segment (i.e. 2 cm) must lie below the mark.
    
2. 5.Show
   From the starting point, using a ruler, mark along the ulnar aspect of the arm at 4‐cm intervals up to the axilla.
   Reducing the limb to 4‐cm segments improves the accuracy of measurement since these segments resemble a cylinder more closely than does the whole limb (Williams and Whitaker [286], E).
3. 6.Show
   Place the tape measure around the limb and measure the circumference at each marked point, recording each measurement on the chart. Make sure that the tape lies smoothly around the relaxed limb and that it does not lie at an angle. Decide at the outset whether the tape is to be placed above, below or on the mark and keep to the same position every time.
   Ensuring that there are no gaps between the limb and the tape and that the procedure is the same each time reduces error (Williams and Whitaker [286], E).
4. 7.Show
   Repeat the process on the other arm.
   If only one limb is affected, the normal limb acts as the patient's own control (Williams and Whitaker [286], E).
5. 8.Show
   If desired, a circumference measurement may be taken of the hand but this is not included in the calculation of volume.
   The hand cannot be considered to be a cylinder and it is therefore inappropriate to include it in the calculation. E
6. 9.Show
   Ensure that the same number of measurements are made and clearly recorded on the record sheet for each arm.
   Accurate documentation will ensure accuracy during limb volume calculation for each limb (Williams and Whitaker [286], E).

Post‐procedure

1. 10.Show
   Remove the marks from the patient's skin using warm water and a mild soap preparation.
   Removing the marks maintains patient dignity. Mild soap ensures that the skin is not irritated. E