General information about LUPUS

1. LUPUS ERYTHEMATOSIS
• In this online lecture
you will learn about the
two types of lupus,
including treatments,
and interventions.
• The two types are:
– Discoid Lupus
Erythematous (DLE)
– Systemic Lupus
Erythematous (SLE)

2. The readings that accompany
this lecture are:
• Reading Assignment
• Iggy- pp 429-436

4. What is Discoid Lupus
Erythematous?
• A chronic skin condition of sores with
inflammation and scarring favoring the
face, ears, and scalp and at times on other
body areas.
• These lesions develop as a red, inflamed
patch with a scaling and crusty
appearance. The center areas may
appear lighter in color with a rim darker
than the normal skin.

5. What does DLE look like?
• Lesions are treated with topical
cortisone, or cortisone injections
• If the cortisone is ineffective the
client maybe treated with
Plaquenil (***please click on this
link to learn more about the
medication***)
• a skin biopsy needs to
be done to confirm the
diagnosis because
other conditions can
look like discoid lupus
erythematosus.

6. What causes DLE?
• The exact cause is unknown, but it is thought to
be autoimmune with the body's immune system
incorrectly attacking normal skin.
• This condition tends to run in families. Females
out number males with this condition 3 to 1.
• In some patients with discoid lupus
erythematosus, sunlight and cigarette smoking
may make the lesions come out.

7. What interventions will help with
DLE?
• Patients whose condition is sensitive to
sunlight need to wear a UVA blocking
sunscreen daily and a hat while out doors.
• Follow-up with the doctor is important and
necessary every six months to once a year
to make sure the disease is not spreading to
the internal organs and to minimize scarring
• If the client is taking Plaquenil yearly eye
exams are a must.

10. What is Systemic Lupus
Erythematosus (SLE)?
• SLE is a complex chronic connective-tissue
disease.
• It affects almost all body systems.
• The manifestations are widely variable but they
are thought to be the result of cell and tissue
damage caused by the deposition of antigen-
antibody complexes in connective tissues.
• SLE can range from a mild, episodic disorder to
a rapidly fatal disease process.

11. What is the epidemiology of
SLE?
• Females are affected more than males in
a ratio of 9:1
• The disease usually affects women of
childbearing age, but can occur at any
age.
• It is more common in African Americans,
Hispanics, and Asians than it is in
Caucasians.

12. What is the etiology of SLE?
• The exact etiology is unknown.
• Genetic, environmental and hormonal factors play a role in its
development.
• The above statements are idiopathic forms of SLE. It can also be
drug induced by the following medications:
• Procainamide
• Isoniazid
• Hydralazine
• Minocycline
• Phenytoin
• Ethosuximide
• D-Penicillamine
– Manifestations of drug induced lupus usually resolve when the
medication is discontinued.

13. What are the initial symptoms of
SLE?
• The initial manifestations of SLE are:
fatigue, fever, malaise, weight loss,
musculoskeletal manifestations similar to
arthritis.
• SLE can affect multiple systems. Let’s
take a look at each of those systems.

14. What are the dermatological
signs?
– The client may have Cutaneous Lupus
Erythematosus
– Malar "butterfly" rash
– Photosensitivity
– Vasculitis
– Alopecia
– Oral Ulcers
– Sicca Syndrome

15. What are the neurological
symptoms?
A client may have the
following symptoms:
• Neuropathies (peripheral
and central)
• Seizures
• Depression
• Psychosis
A client may have the
following complications
from an exacerbation of
SLE:
• CVA
• Organic Brain Syndrome
– Intellectual impairment
– Memory Loss
– Personality Changes
– Disorientation

16. What kinds of ocular changes
can result from SLE?
• Conjunctivitis
• Photophobia
• Retinal vasculitis with transient blindness
• Cotton-wool spots on retina
Cotton wool spots are small areas of yellowish white
coloration in the retina. They occur because of
swelling of the surface layer of the retina, which
consists of nerve fibers. This swelling almost always
occurs because the blood supply to that area has
been impaired and in the absence of normal blood
flow through the retinal vessels the nerve fibers are
injured in a particular location resulting in swelling and
the appearance of a "cotton wool spot. "

17. What are the musculoskeletal
changes with SLE?
• Morning Stiffness
• Arthralgias
• Symmetric Polyarthritis
• Joint Swelling and Effusion

18. How can SLE effect the renal
system?
• Proteinuria
• Cellular casts
Potential complications
resulting from SLE
are:
• Nephrotic syndrome
• Renal failure

19. How can SLE effect the GI
system?
• Hepatomegaly
• Anorexia
• Nausea
• Abdominal Pain
• Diarrhea

20. How can SLE effect the
Cardiovascular system?
• Pericarditis
• Myocarditis
• Endocarditis
• Vasculitis
• Venous or arterial
thrombosis (anywhere
in the body)

21. How does SLE effect the
hematologic system?
• Anemia
• Leukopenia
• Thrombocytopenia
• Splenomegaly

22. How can SLE effect the
Respiratory System?
• Pleurisy
• Pleural effusion
• Pneumonitis
• Interstitial fibrosis

23. What Lab Assessments help in
the diagnosis?
• Initially and ANA titer is completed. *Please
remember an ANA titer alone cannot be used to diagnose a disease, it
must be used in combination with an evaluation of symptoms and other
tests.
• Secondary testing if the ANA titer positive
– Complete Blood Count *** pay particular attention to the
WBC, Hgb & Plt counts**
– Coagulation factors
– Urinalysis
– Serum Creatinine
– Antiphospholipid Antibody
– Double Stranded DNA Antibody (Anti-dsDNA)
– Smith Antibody (Anti-Smith or Anti-Sm)

24. How is a diagnosis of SLE
made?
• A diagnosis of SLE is made when a client has 4 of 11
following criteria:
– Malar Rash
– Discoid rash
– Photosensitivity
– Oral Ulcers
– Polyarthritis involving more than 2 joints
– Pleuritis or Pericarditis
– Antinuclear Antibody positive titer
– Renal disease
– Neurologic disorder (e.g. Seizures, Psychosis)
– Anemia, Neutropenia or Thrombocytopenia
– Anti-dsDNA, Anti-Sm positive

25. How is SLE treated?
Part of the treatment of SLE involves the use of medications
– Salicylates and NSAIDs
• Enteric Coated ASA 650 mg PO every 4-6 hours prn
• Ibuprofen 400-800 mg PO tid-qid prn
– Anti-Malarial agents
• Hydroxychloroquine (Plaquenil) 400 mg/day
– Corticosteroids
• Topical Corticosteroids
• Systemic Corticosteroids in severe exacerbations
– Prednisone 0.5 to 1 mg/kg/day up to 4 weeks or
– Solu-medrol 15 mg/kg IV for 3 days
– Cytotoxic agents or antineoplastic drugs are effective immunosuppressive
agents. **They act by decreasing the proliferation of cells within the immune system and
are widely used to prevent rejection following a tissue of organ transplant. They are usually
adminstered concurrently with corticosteriod therapy, allowing lower doses of both
preparations, and resulting in fewer side effects.**
• Cyclophosphamide (cytoxen)
– Daily dosing: 1.5-2.5 mg/kg/day or
– Monthly dosing: 10-15 mg/kg IV every 4 weeks
• Azathioprine (Imuran) 2-3 mg/kg/day

26. What else does a client with SLE
need?
• A client with SLE also needs Opthamology
exams with dilation upon starting steriods or
plaquenil and yearly there after.
• Interventions to reduce fatigue.
• Sunscreen and other protection against
photosensitivity.
• Interventions to prevent infection.
• Birth control is critical during exacerbations.

27. How does a client diagnosed with
SLE feel?
Clients with SLE may
have problems with
the following:
– SELF ESTEEM
– WITHDRAWAL
– DEPRESSION
– PSYCHOSIS
– HARDINESS
– MANAGEMENT OF A
CHRONIC ILLNESS

28. What are the outcomes?
Although there is no cure for SLE, the 10
year survival rate is greater than 70%
among clients with this disease, which
once was considered fatal in most cases.
• Click on the following link to watch a video about
Lupus and initiatives regarding the disease
http://www.lupusresearchinstitute.org/video.php

30. A Case Study
• D.W. is a 23 year old married woman with
3 children under the age of 5. She
presented to her physician 2 years ago
with vague complaints of intermittent
fatigue, joint pain, and low-grade fever.
Her physician noted a scaly rash across
her nose cheeks, back and chest at that
time.

31. Laboratory Results Revealed
• Positive antinuclear antibody titer
• Positive Lupus Erythematosus cell prep
• Elevated C-reactive protein
• Elevated ESR
• Hgb 10 g/dL
Joint X-rays revealed joint swelling in
bilateral knees without joint erosion.

32. What is the diagnosis: systemic
lupus erythematosus or
cutaneous lupus
erythematosus?
• D.W. was diagnosed with systemic lupus
erythematosus.
– The malar rash
– Polyarthritis
– Anemia
– Positive ANA titer

33. How does discoid lupus
erythematosus differ from
systemic lupus erythematosus?
• DLE
– Topical skin disorder
– An autoimmune
disorder attacking the
skin
• SLE
– A systemic
autoimmune
multi-system disorder
– An episodic disorder
– May include DLE

34. • D.W. was subsequently diagnosed with
systemic lupus erythematosus. She was
initially treated with Cyclophosphamide
(cytoxen) 150mg PO every day and
prednisone (Deltasone) 20 mg po every
day, bedrest, ice packs, and aspirin to
control discomfort.

35. What priorities need to be
addressed with D.W.?
• Monitor blood count with particular attention to
WBC and platelet counts. Notify the physician if
the WBC’s fall below 4000, or platelets below
75,000.
• Monitor renal & liver function studies
• Cytoxen should be administered with food to
minimize gastrointestinal effects
• Monitor for signs of abnormal bleeding
• Use meticulous hand washing and assess for
signs of infection
• Ensure adequate nutrient intake

36. • D.W. responded well to treatment and
resumed her job in environmental services
at a large geriatric facility. Eighteen
months after diagnosis, D.W. developed
puffy hands and feet and increased
fatigue. D.W. reported that she had been
working longer hours because of the
absence of 2 of her fellow workers.

37. Diagnostic Evaluation Revealed:
BUN 29 mg/dL
Creatinine 1.5 mg/dL
Urinalysis
+2 protien
+1 RBC

38. • What are the significance of these
findings?
• What is the relationship of such findings to
D.W.’s diagnosis of SLE?
• How will D.W.’s treatment and nursing
plan likely to change?
(**Hint – This is a great place to apply your
Renal Content****)

39. • There will be a pass session on Lupus to
discuss and questions and talk about the
case study. Hope to see you there.
• For any other questions please see Jean
or email her at jforsha@ccp.edu