Med-Surg: Chapter 20: Systemic Lupus Erythematosus (SLE) Flashcards
Systemic Lupus Erythematosus (SLE)
- autoimmune disorder
- chronic inflammatory disease; affects any organ system
- etiology unknown
- clinical manifestations are attributed to antibodies and the creation of immune complexes that are deposited into the tissues
Triggering Factors
- pregnancy
- exposure to sunlight
- illness
- major surgery
- silica dust
- medication allergies
What are the Clinical Manifestations attributed to?
antibodies and the creation of immune complexes that are deposited into tissues
Clinical Manifestations
-diverse; do not follow a clinical pattern; and vary greatly from person to person
> Constitutional:
- fatigue
- fever
- difficulty concentrating
> Mucocutaneous
- rash; Malar (butterfly rash) across cheeks
- discoid lesions, erythematous plaques covered by scale that typically appear on sun-exposed areas
- photosensitivity
- alopecia
- urticaria (hives), palpable purpura (purple spots), erythematous papules of fingers and palms, splinter hemorrhages, and digital ulcers caused by vasculitis
- oral, nasal, and anogenital ulcers
> Musculoskeletal
- joint pain with or without synovitis
- muscle pain and weakness
> Renal
- lupus nephritis
- proteinuria
- hematuria (blood in urine)
> Neurological
- stroke
- seizures
- neuropathy
- psychosis
- organic brain syndrome
- depression
- anxiety
> Cardiovascular
- pericarditis
- endocarditis
- increased risk of cardiovascular disease
> Pulmonary
- pleurisy (inflammation of the tissues that line the lungs and chest cavity)
- pleural effusion
- pneumonitis
- interstitial lung disease
- pulmonary hypertension
> Ocular
- retinal lesions
- dry eyes
> Hematological
- leukopenia
- anemia of chronic disease
- thrombocytopenia
- thromboembolism
The clinical course of SLE
involves periods of remission and acute disease flares
Diagnosis
- no specific test
- laboratory findings support or confirm diagnosis when combined with history and physical examination findings
Clinical Criteria to Aid in Diagnosis
-skin rashes (lupus malar rash)
-oral ulcers
-thinning hair
-joint tenderness
-pleural or pericardial effusions
-renal (urine protein) and neurological (seizures/confusion) disorders
-haematological disorders (thrombocytopenia, leukopenia, or anemia)
-immunological criteria: positive antinuclear antibody (ANA), low complement, positive anti-SM, antiphospholipid antibodies, and positive anti-double-stranded DNA (anti-dsDNA)
>four of the 17 criteria must be present
Laboratory Testings
- first, testing is done to confirm the presence of autoantibodies
- patients with SLE produce antinuclear antibody (ANA), confirming the existence of an autoimmune disease
- Anti-dsDNA and anti-Sm antibodies are most specific for SLE
- antiphospholipid antibodies should be assess b/c these antibodies may lead to formation of blood clots
- CBC to check for leukopenia (decreased WBC count), thrombocytopenia (decreased platelet count), and anemia (decreased RBCs)
- urinalysis with random protein and creatinine along with serum creatinine and BUN to detect kidney disease
- C-reactive protein and ESR may be monitored to identify inflammation but not specific for SLE; also be monitored for level of disease activity and response to treatment
Radiographical Imaging
> Plain Radiograph
- to assess for joint damage– painful, swollen joints
- chest– assess for lung disease and cardiomegaly
> Ultrasound
-kidneys– assess size and r/o obstruction if there is evidence of renal impairment
> Echocardiogram
-assess for pericardial involvement and elevated pulmonary artery pressure (SLE patients are at risk for developing pulmonary artery hypertension)
> CT
- abdominal pain- assess for pancreatitis
- chest– assess for interstitial lung disease
> MRI
-brain–assess neurological defects and cognitive dysfunction
Non-pharmacological Therapy
- avoid prolonged sun exposure
- use sunscreen (SPF 50 or higher) on a daily basis
- well-balanced diet
- frequent rest periods and regular sleep schedule help combat fatigue
- regular exercise improves strength and maintain range of motion and healthy weight
Pharmacological Therapy
based on manifestations
- Antimalarial (hydroxychloroquine (Plaquenil))
- NSAIDs (ibuprofen)
- Glucocorticoids
- Immunosuppressive agents (methotrexate)
- biological response modifier (Belimumab)
Hydroxychloroquine (Plaquenil)
antimalarial
-believed to impair complement-dependent antigen-antibody reactions
-useful in treating constitutional symptoms (fatigue, skin and joint manifestations)
-helps prevent disease flares and serious organ disease such as lupus nephritis
>Side effects: abdominal pain and nausea; may improve over time
>required to have a baseline eye examination and then biannual or annual eye examination to assess for retinal toxicity, which may be caused by long-term use
NSAIDs
ibuprofen -useful in treating arthralgias, myalgias, headaches, and fever >use for: -musculoskeletal complaints -fever -headaches -mild pleuritis or pericarditis
> should not be used in patients with renal impairment b/c of the inhibition of the prostaglandins responsible for preserving renal blood flow
Glucocorticoids
suppress inflammation in joints, kidneys, and other organ systems
> low dose oral glucocorticoids
- for joint pain with active synovitis
- rash
> high dose oral glucocorticoids
- nephritis
- pneumonitis
- hematological abnormalities (thrombocytopenia)
- CNS disease
- systemic vasculitis
> Topical glucocorticoids (clobetasol)
-skin rash and oral/nasal ulcers
Immunosuppressive Agents
- Methotrexate
- Others: Azathioprine, Cyclophosphamide, Mycophenolate mofetil, Thalidomide
- treat joint inflammation and synovitis
- tx of mild to moderate disease activity and as an alternative to long-term use of glucocorticoids; used to treat lupus nephritis and other organ-threatening manifestations
- tx of severe SLE: lupus nephritis, CNS disease, pulmonary hemorrhage, and systemic vasculitis
- prevention of renal allograft rejection
- chronic cutaneous lupus
Biological Response Modifier
Belimumab (Benlysta)
- made of monoclonal antibodies that bind to proteins known as BLyS and interferes with the inflammatory cascade, decreasing the immune response that is responsible for causing clinical manifestations
- used in conjunction with traditional medications in SLE patients with serologically active disease
Safety Alert: NSAIDs
should not be used in patients with renal impairment
Safety Alert: Hydroxychloroquine (Plaquenil)
required to have a baseline eye examination and then biannual or annual eye examination to assess for retinal toxicity, which may be caused by long term use
Surgical Management
- may include renal transplant for patients with severe lupus nephritis
- joint replacement for patients at risk for avascular necrosis of large joints
Complications of Lupus
- renal failure
- premature heart disease
- interstitial lung disease
- hypercoagulation
- stroke
- avascular necrosis of joints
- increased risk for infection
Nursing Management: Assessment and Analysis
many clinical manifestations; etiology unknown; thought to be attributed to antibodies and the creation of immune complexes, which are deposited into the tissues
- fatigue
- difficulty concentrating
- joint pain
- rash
- photosensitivity
- oral or nasal ulcers
- dry eyes
- dry mouth
- hypertension
- leukopenia
- thrombocytopenia
- alopecia
- chest pain
Nursing Diagnoses
- fatigue r/t chronic inflammation and altered immunity
- altered skin integrity r/t rash
- altered self-image r/t manifestations such as rash and alopecia
Nursing Interventions: Assessments
> Vital Signs
- hypertension may occur as a renal or cardiac complication of SLE
- fever may be present due to infection that is a complication of tx with immunosuppressants
- decreased oxygen saturation may be present b/c of the complication of interstitial lung disease
> Past health history/ head-to-toe assessment
-diagnosis of SLE is based on presence of 4 of 17 clinical manifestations in the history and physical assessment such as butterfly rash, oral or nasal ulcers, alopecia, musculoskeletal complaints, joint swelling, weight loss, and blood abnormalities
> Lab values: BUN and creatinine, Urinalysis, CBC, CRP/ESR, coagulation studies
- Elevated BUN and creatinine along with presence of proteinuria may = decreased renal function and is one of the clinical criteria for SLE
- Decreased WBC, platelets, and RBCS common and may require intervention
- Elevated CRP and/or ESR indicates inflammation and may require intervention
- Coagulopathies are a complication of SLE
Nursing Actions
> Administer analgesics and anti-inflammatory medications
-most patients require regular analgesics and anti-inflammatory medications to manage the pain caused by inflammation
> Administer medications as ordered to treat specific clinical manifestations
Teaching
> Disease process
> Use Sunscreen daily
- photosensitivity is common
- helps prevent rash r/t photosensitivity
> Energy Conservation and activity prioritization
-fatigue is a common complaint and can be managed by frequent rest periods and prioritizing activities
> Keep up to date on immunizations, but avoid live vaccines
-patients at risk for infections due to tx should not receive live vaccines if on immunosuppressive therapy
> Avoid oral contraceptives in patients with SLE who have migraine headaches, Raynaud’s Phenomenon, a history of phlebitis, or antiphospholipid antibodies
-patients with SLE have a higher risk of hypercoagulability, which may be heightened with use of oral contraceptives
> refer to pulmonologist, nephrologist, neurologist, cardiologist, and dermatologist as needed
Evaluating Care Outcomes
- lupus is a complicated disease that can be difficult to manage
- medication compliance
- disease flares are not unexpected and may consist of increased fatigue, fever, rash, arthritis, and mucosal ulcers
- frequent evaluations should be performed on a regular basis by a rheumatologist who monitors disease progression and treats new manifestations as they arise
- well-controlled SLE are high-functioning individuals who are able to carry out the usual activities of daily living
