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Risk assessment of skin in rheumatic disease.

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VOL: 101, ISSUE: 24, PAGE NO: 54

Jill Firth, BSc, RGN, is honorary rheumatology nurse specialist, Bradford Hopitals NHS Trust, and a Smith & Nephew Foundation doctoral nursing research student at the University of Leeds

This paper focuses on the process of tissue viability risk assessment for patients with rheumatic disease and questions how useful risk assessment tools are in helping nurses to identify risk factors and initiate appropriate care in this client group. The Waterlow Risk Assessment Card (Box 1) (Waterlow, 1998) is examined for its potential to identify risk factors affecting tissue viability in rheumatic disease. This particular card was chosen because it is the most commonly used risk assessment system in the UK.

This paper focuses on the process of tissue viability risk assessment for patients with rheumatic disease and questions how useful risk assessment tools are in helping nurses to identify risk factors and initiate appropriate care in this client group. The Waterlow Risk Assessment Card (Box 1) (Waterlow, 1998) is examined for its potential to identify risk factors affecting tissue viability in rheumatic disease. This particular card was chosen because it is the most commonly used risk assessment system in the UK.

The Waterlow card
The Waterlow card (Box 1) was developed primarily as a practical tool to improve the assessment of patients at risk of developing pressure ulcers and to promote their prevention and treatment through in-service training (Waterlow, 1998).

Following considerable research, the card was updated to include guidance on prevention, wound care and general patient care (Waterlow, 1998; 1991). Although the emphasis is on risk assessment, prevention and treatment relating to pressure ulcers, the promotion of tissue viability in a wider sense requires attention to the same specific areas identified in the risk assessment card.

According to Griffiths-Jones (1991) the nursing process offers 'a valuable structured approach for nurses faced with the complex problems of modern wound management'. The process of assessment, planning, implementation and evaluation facilitates an individualised approach to care as well as co-operation between the nurse, patient and members of the multidisciplinary team.

Using a risk assessment card that has been designed to enhance this process and claims to be accurate, quick and simple to use (Waterlow, 1998; 1991) can only be beneficial. However, despite fulfilling these criteria, how accurately does the card highlight risk factors in rheumatic disease, and what are the implications for patient care and rehabilitation? To address this question the Waterlow scoring system (Box 1) is examined in relation to the assessment of a patient with rheumatic disease.

Analysis of risk assessment in rheumatic disease
The following analysis of risk assessment relates knowledge of the factors affecting tissue viability in rheumatic disease to the categories defined in the Waterlow card (Box 1), and offers recommendations for practice.

Build/weight for height - Osteoarthritis is more common in women over 50 years and there is an association with obesity, whereas rheumatoid arthritis is more common in women aged between 20 and 50, and may be associated with profound weight loss (le Gallez, 1995). Weight loss can occur in conjunction with any inflammatory arthritis or connective tissue disorder and is thought to be related to cytokine-driven hypermetabolism (Roubenoff et al, 1992). Below-average weight is a significant risk factor in the development of pressure ulcers, as bony prominences are exposed owing to loss of subcutaneous fat (Mairis, 1992; Morison, 1992). Attention should be paid to correct moving and handling techniques when caring for patients with below-average weight, and pressure-relieving mattresses and chairs should be provided. A tool such as the Waterlow card, together with its treatment policy, can help to justify expenditure on pressure-relieving equipment.

Visual skin type - The Waterlow card is designed so that several scores in each category may be used (Waterlow, 1998) (Box 1). When assessing the skin of a patient with rheumatic disease it is important to note the presence and extent of psoriasis, vasculitis or cutaneous involvement.

Extra-articular features in a patient with rheumatoid arthritis may include subcutaneous rheumatoid nodules over bony prominences anywhere in the body. It is important to note these as they are thought to be a marker for a poor prognosis. They are often found on pressure-bearing surfaces such as the elbow, and may become ulcerated, which can lead to the development of vasculitis (le Gallez, 1995). Topical or systemic treatment of skin conditions help to maintain skin integrity.

A raised temperature as a result of inflammation or infection, and oedema as a consequence of immobility, cardiac or renal involvement and thrombophlebitis, are also important risk factors for skin integrity (Dunne and Robertson, 1992). Oedema leads to impaired wound healing and increases the risk of tissue breakdown, therefore evaluation of an affected limb and the use of compression stockings, unless contraindicated, are as important as a pressure-relieving intervention (Dunne and Robertson, 1992).

Patients with rheumatoid arthritis should be assessed for arterial or venous disease and ulceration because this condition has been identified as the third most common underlying cause of leg ulceration (Callam et al, 1985; McRorie et al, 1994). These authors concluded that leg ulcers in patients with rheumatoid arthritis are of mixed aetiology (having a venous and arterial component) and are more resistant to treatment. Early and effective intervention, combined with patient education, is required for these patients.

It is also important to check the condition of a patient's feet, because reduced hand function and restricted movement may mean that personal foot care is often not possible. Rheumatoid arthritis, Reiter's disease and psoriatic arthritis may all affect the bones and soft tissues of the feet. The resulting alterations in gait and pressure over dropped metatarsal heads can cause corns and callosities that may ulcerate if left untreated. Referral to a podiatrist for foot care and the provision of insoles and specialist footwear is imperative to maintain skin integrity.

Appetite - Healthy skin requires a diet rich in protein, calories, vitamins and minerals and an adequate fluid intake (Morison, 1992). Ryan (1995) highlighted that the systemic nature of rheumatoid arthritis raises the energy expenditure for basic cellular function. During the active phase, the individual's metabolic rate and calorie and protein requirements increase. All wound healing, whatever the origin of the wound - traumatic, surgical or chronic - is marked by increased cell activity, which adds to the metabolic demands on the body (Torrance, 1990).

The issue of nutrition is addressed by Waterlow (1998) in terms of appetite. For the patient with rheumatic disease, appetite may be affected by a number of factors, including Sjogren's syndrome (an associated disease), which causes a dry mouth, or the side-effects of drugs. For example, penicillamine may cause loss of taste, a number of the disease-modifying drugs can cause nausea, and non-steroidal anti-inflammatory drugs (NSAIDs) may cause gastro-intestinal discomfort (Ryan, 1995). Loss of appetite may be due to pain, fatigue, anxiety or depression. Furthermore, eating patterns may be affected by admission to hospital (Ryan, 1995).

However, while appetite is an important consideration in assessing the nutritional status of an individual, it is clearly only one factor. Patients with rheumatoid arthritis may physically be unable to shop or prepare food or they may have difficulty eating. In addition to pain and fatigue, immobility, stiffness and deformity may hinder the preparation and consumption of food.

Any problems related to dietary intake mean that comprehensive nutritional assessment will be necessary. This will involve the dietitian, the occupational therapist and other members of the multidisciplinary team.

Mobility - The stages of mobility assessed by the Waterlow card range from being fully mobile to being inert/on traction and chair-bound. Between these extremes there are scores for patients who are restless/fidgety, apathetic or restricted in their mobility. It is possible to attribute scores to patients with a rheumatic disease whose mobility is restricted by pain, stiffness, deformity or disability and who are affected by fatigue. This does, however, depend on the nurse being proactive and appreciating the impact of rheumatic disease.

Crosby (1991) identified the three most frequently identified factors contributing to fatigue in rheumatoid arthritis: disease activity; disturbed sleep and increased physical effort. Symptoms of fatigue affecting mobility include exhaustion, loss of initiative and reduced motivation. Fatigue may cause patients to sit for long periods without adjusting their position, which increases the risk of their developing pressure ulcers. Disturbed sleep may also affect tissue renewal, as sleep appears to be the time of maximum anabolic activity. According to Torrance (1990), sleep is marked by peak protein synthesis, cell proliferation, metabolism of amino acids and growth hormone secretion.

Helping patients meet basic needs such as rest and sleep, relieving their pain and suggesting therapeutic exercise all require sensitive and informed management. Intervention may take the form of adjusting medication, or giving simple advice about the need to relieve pressure by changing position. The patient's armchair should promote good posture, be the appropriate height, have a suitable patient-cushion interface and facilitate independent standing (Morison, 1992). Likewise, the patient's mattress should meet the needs of the patient as identified by the Waterlow treatment policy (Waterlow, 1991).

Continence - Adams et al (1994) suggest that anatomical urinary stress incontinence in women with rheumatoid arthritis may occur as a result of damaged connective tissue affecting pelvic floor structures. However, a poor response rate to their survey weakens the reliability of their results in relation to the incidence of incontinence in rheumatoid arthritis. Despite this, the study highlights that little attention is given to investigating and treating continence problems. Embarrassment may also hinder patients from seeking advice and practical help. Urinary tract infection and difficulty in reaching toilet facilities in time owing to restricted mobility may also cause continence problems.

Addressing the cause of incontinence may reduce the risk of skin breakdown associated with urine contaminating the skin (Morison, 1992). Referral to a continence adviser or liaison with the district nursing team may also be beneficial.

Special risks
Peripheral vascular disease significantly depletes tissue viability as a result of reduced oxygenation to the tissues and removal of carbon dioxide and the waste products of metabolism. Venous insufficiency and arterial disease appear to be prevalent in patients with rheumatoid arthritis. Peripheral vascular problems in rheumatic disease may also be a result of Raynaud's phenomenon, which can be a feature of connective tissue disease. Peripheral neuropathy can be a complication of rheumatic diseases (Ferguson and Hollingworth, 1998) and if there is sensory loss and damage to the skin, the condition may go undetected until tissue breakdown has occurred.

Anaemia reduces the quality of blood perfusing the peripheral tissues, so impairing healing (Bird et al, 1985).

Medication - Risks related to medication are identified in the Waterlow card as anti-inflammatory drugs, steroids and cytotoxic drugs, all of which are regularly used in the treatment of rheumatic diseases. The effects of newer agents, such as tumour necrosis factor-alpha inhibitors - etanercept and infliximab, for example - on tissue viability are now under scrutiny.

Non-steroidal anti-inflammatory drugs (NSAIDs) can inhibit platelet aggregation, mildly increasing bleeding time in patients and increasing the risk of bruising and haematoma. They can also affect the wound healing of soft tissues (Hart et al, 2004).

Corticosteroids are powerful anti-inflammatory drugs, but their systemic use also exerts a profound inhibitory effect on wound healing (Fincham Gee, 1991). Reducing inflammation will suppress the mechanisms for tissue repair and interfere with the proliferative phase of wound healing. Steroids also inhibit wound contracture and delay epithelialisation. This combination of delayed healing and inhibition of antimicrobial activity leads to increased risk of infection (Anstead, 1998). Steroids result in a thinned abnormal dermis and epidermis (Fincham Gee, 1991). This means there is an increased risk of a patient developing pressure ulcers. The general fragility of the skin means that very careful handling of the patient is required.

Patient education concerning the side-effects of drug therapy should include an awareness of the need for extra care in relation to skin conditions and the importance of carrying a card to alert health-care professionals that steroids are being taken.

Immuno-suppressive and cytotoxic drugs, such as penicillamine and methotrexate, are believed to delay healing and reduce resistance to infection (Tudor and Gupta, 1992). Their review of the literature and additional research by Escalante and Beardmore (1995) into the effect of anti-rheumatic drugs on the frequency of early wound problems following orthopaedic surgery is inconclusive. The findings of Escalante and Beardmore (1995) highlight the importance of considering all risk factors that may influence the outcome of joint surgery before assuming that any one variable has a causative role.

Major surgery - Surgery is often part of the long-term management of patients with inflammatory arthritis. Where degenerative arthritis affects a joint, replacement surgery is offered, with the aim of achieving pain relief and maintaining or improving function. It is important that the needs of patients with rheumatoid disease and multiple joint involvement are recognised by nurses working in orthopaedic surgery.

Discussion
Following consideration of all the risk factors potentially identified in a Waterlow assessment, there appears to be a fundamental omission. Rheumatoid arthritis is widely recognised as a generalised disorder of connective tissue involving extra-articular structures as well as joints. Complex immunological changes can be observed in the blood and tissues of patients with rheumatoid disease that affect phagocytosis and specific immunity defence mechanisms (Bird et al, 1985; Morison, 1992). A risk assessment should highlight the increased risk of these patients developing pressure ulcers, poor tissue viability and reduced resistance to infection.

Awareness of the disease process and its effects on tissue viability will facilitate accurate scoring of risk. According to Waterlow (1991): 'the card belongs to the user, and is intended to benefit the patients ... it should not be considered as a tablet of stone to be followed or rejected slavishly'. It may be reasonable to propose that, in order to guide junior staff and students, scores of between two and four may be attributed for rheumatic disease, depending on the severity and extent of illness. The greater the perceived risk the more justification there is for nursing intervention and the use of resources to prevent pressure ulcers and promote tissue viability. This should include time being spent on health education for patients and carers, the teaching of colleagues and the use of pressure-relieving mattresses and seat cushions.

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