Systemic Lupus Eritematosus

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Systemic LupusSystemic Lupus
Erythematosus (SLE)Erythematosus (SLE)

Systemic LupusSystemic Lupus
Erythematosus (SLE)Erythematosus (SLE)
• Chronic multisystem inflammatoryChronic multisystem inflammatory
diseasedisease
• Associated with abnormalities ofAssociated with abnormalities of
immune systemimmune system
• Results from interactions amongResults from interactions among
genetic, hormonal, environmental,genetic, hormonal, environmental,
and immunologic factorsand immunologic factors

Systemic Lupus ErythematosusSystemic Lupus Erythematosus
• Affects theAffects the
 SkinSkin
 JointsJoints
 Serous membranesSerous membranes
 Renal systemRenal system
 Hematologic systemHematologic system
 Neurologic systemNeurologic system

Systemic Lupus ErythematosusSystemic Lupus Erythematosus
• A variable diseaseA variable disease
 ChronicChronic
 UnpredictableUnpredictable
 Characterized by exacerbations &Characterized by exacerbations &
remissionsremissions

IncidenceIncidence
• SLE affects 2 to 8 persons perSLE affects 2 to 8 persons per
100,000 in United States100,000 in United States
• Most cases occur in women ofMost cases occur in women of
childbearing yearschildbearing years
• African, Asian, Hispanic, and NativeAfrican, Asian, Hispanic, and Native
Americans three times more likely toAmericans three times more likely to
develop than whitesdevelop than whites

EtiologyEtiology
• Etiology is unknownEtiology is unknown
• Most probable causesMost probable causes
 Genetic influenceGenetic influence
 HormonesHormones
 Environmental factorsEnvironmental factors
 Certain medicationsCertain medications

PathophysiologyPathophysiology
• Autoimmune reactions directedAutoimmune reactions directed
against constituents of cell nucleus,against constituents of cell nucleus,
DNADNA
• Antibody response related to B andAntibody response related to B and
T cell hyperactivityT cell hyperactivity

Clinical ManifestationsClinical Manifestations
• Ranges from a relatively mildRanges from a relatively mild
disorder to rapidly progressing,disorder to rapidly progressing,
affecting many body systemsaffecting many body systems
• Most commonly affects theMost commonly affects the
skin/muscles, lining of lungs, heart,skin/muscles, lining of lungs, heart,
nervous tissue, and kidneysnervous tissue, and kidneys

Fig 65-9Fig 65-9

• DermatologicDermatologic
 Cutaneous vascular lesionsCutaneous vascular lesions
 Butterfly rashButterfly rash
 Oral/nasopharyngeal ulcersOral/nasopharyngeal ulcers
 AlopeciaAlopecia

Dermatologic ManifestationsDermatologic Manifestations
Fig 65-10Fig 65-10

• MusculoskeletalMusculoskeletal
 Polyarthralgia with morning stiffnessPolyarthralgia with morning stiffness
 ArthritisArthritis
• Swan neck fingersSwan neck fingers
• Ulnar deviationUlnar deviation
• Subluxation with hyperlaxity of jointsSubluxation with hyperlaxity of joints

Swan Neck DeformitySwan Neck Deformity
Fig. 65-4 DFig. 65-4 D

• CardiopulmonaryCardiopulmonary
 TachypneaTachypnea
 PleurisyPleurisy
 DysrhythmiasDysrhythmias
 Accelerated CADAccelerated CAD
 PericarditisPericarditis

• RenalRenal
 Lupus nephritisLupus nephritis
• Ranging from mild proteinuria toRanging from mild proteinuria to
glomerulonephritisglomerulonephritis
• Primary goal in treatment is slowing thePrimary goal in treatment is slowing the
progressionprogression

• Nervous systemNervous system
 Generalized/focal seizuresGeneralized/focal seizures
 Peripheral neuropathyPeripheral neuropathy
 Cognitive dysfunctionCognitive dysfunction
• DisorientationDisorientation
• Memory deficitsMemory deficits
• Psychiatric symptomsPsychiatric symptoms

• HematologicHematologic
 Formation of antibodies against bloodFormation of antibodies against blood
cellscells
 AnemiaAnemia
 LeukopeniaLeukopenia

• Hematologic (cont’d)Hematologic (cont’d)
 ThrombocytopeniaThrombocytopenia
 CoagulopathyCoagulopathy
 Anti-phospholipid antibody syndromeAnti-phospholipid antibody syndrome

• InfectionInfection
 IncreasedIncreased susceptibility to infectionssusceptibility to infections
 Fever should be considered seriousFever should be considered serious
 Infections such as pneumonia are aInfections such as pneumonia are a
common cause of deathcommon cause of death

Diagnostic StudiesDiagnostic Studies
• No specific testNo specific test
• SLE is diagnosed primarily onSLE is diagnosed primarily on
criteria relating to patient history,criteria relating to patient history,
physical examination, and laboratoryphysical examination, and laboratory
findingsfindings

• Antinuclear antibodiesAntinuclear antibodies
 ANA and other antibodies indicateANA and other antibodies indicate
autoimmune diseaseautoimmune disease
 Anti-DNA and anti-Smith antibody testsAnti-DNA and anti-Smith antibody tests
most specific for SLEmost specific for SLE
 LE prep can be positive with otherLE prep can be positive with other
rheumatoid diseasesrheumatoid diseases
 ESR & CRP are indicative of inflammatoryESR & CRP are indicative of inflammatory
activityactivity

Diagnostic TestsDiagnostic Tests
• CBC for hematologic problemsCBC for hematologic problems
• UA for lupus nephritisUA for lupus nephritis
• X-rays of affected jointsX-rays of affected joints
• Chest x-ray for pulmonary problemsChest x-ray for pulmonary problems
• ECG for cardiac problemsECG for cardiac problems

Collaborative CareCollaborative Care
• Prognosis is improved withPrognosis is improved with
 Earlier diagnosisEarlier diagnosis
 Earlier and better treatment regimensEarlier and better treatment regimens
 Careful monitoring for organCareful monitoring for organ
involvementinvolvement

Collaborative CareCollaborative Care
• Drug therapyDrug therapy
 NSAIDsNSAIDs
 Antimalarial drugsAntimalarial drugs
 Steroid-sparing drugsSteroid-sparing drugs
 CorticosteroidsCorticosteroids
 Immunosuppressive drugsImmunosuppressive drugs

Nursing ManagementNursing Management
Nursing AssessmentNursing Assessment
• Assess patient’s physical,Assess patient’s physical,
psychologic, and socioculturalpsychologic, and sociocultural
problems with long-termproblems with long-term
management of SLEmanagement of SLE
• Assess pain and fatigue dailyAssess pain and fatigue daily

Nursing AssessmentNursing Assessment
• Obtain subjective and objective dataObtain subjective and objective data
• Educate and counsel on expectedEducate and counsel on expected
issuesissues

Nursing DiagnosesNursing Diagnoses
• FatigueFatigue
• Acute painAcute pain
• Impaired skin integrityImpaired skin integrity
• Ineffective therapeutic regimenIneffective therapeutic regimen
managementmanagement
• Body image disturbanceBody image disturbance

PlanningPlanning
• Overall goalsOverall goals
 Have satisfactory pain reliefHave satisfactory pain relief
 Comply with therapeutic regimen toComply with therapeutic regimen to
achieve maximum symptomachieve maximum symptom
managementmanagement

PlanningPlanning
• Overall goals (cont’d)Overall goals (cont’d)
 Demonstrate awareness of, and avoidDemonstrate awareness of, and avoid
activities that cause diseaseactivities that cause disease
exacerbation (triggers)exacerbation (triggers)
 Maintain optimal role function and aMaintain optimal role function and a
positive self-imagepositive self-image

Nursing ImplementationNursing Implementation
• Health promotionHealth promotion
 Prevention of SLE is not possiblePrevention of SLE is not possible
 Promote early diagnosis and treatmentPromote early diagnosis and treatment

• Acute interventionAcute intervention
 During exacerbation, patient willDuring exacerbation, patient will
become abruptly, dramatically illbecome abruptly, dramatically ill
 Record severity of symptoms andRecord severity of symptoms and
response to therapyresponse to therapy

• Acute intervention (cont’d)Acute intervention (cont’d)
 Observe forObserve for
• Fever patternFever pattern
• Joint inflammationJoint inflammation
• Limitation of motionLimitation of motion
• Location and degree of discomfortLocation and degree of discomfort
• FatigabilityFatigability

• Acute intervention (cont’d)Acute intervention (cont’d)
 Monitor weight and I&OMonitor weight and I&O
 Collect 24-hour urine sampleCollect 24-hour urine sample
 Assess neurological statusAssess neurological status
 Explain nature of diseaseExplain nature of disease
 Provide supportProvide support

• Ambulatory and home careAmbulatory and home care
 Reiterate that adherence to treatmentReiterate that adherence to treatment
does not necessarily halt progressiondoes not necessarily halt progression
 Minimize exposure to precipitatingMinimize exposure to precipitating
factors – fatigue, sun, stress, infection,factors – fatigue, sun, stress, infection,
drugsdrugs

• Ambulatory and home careAmbulatory and home care
 Teach energy conservation andTeach energy conservation and
relaxation exercisesrelaxation exercises
 For joint problems, all the teaching forFor joint problems, all the teaching for
RA related to joint protection, ROM,RA related to joint protection, ROM,
and positioning to prevent contracturesand positioning to prevent contractures

• Lupus and pregnancyLupus and pregnancy
 Infertility can result from SLE treatmentInfertility can result from SLE treatment
regimenregimen
 SLE is associated with complications ofSLE is associated with complications of
pregnancypregnancy
 Pregnancy & post partum can causePregnancy & post partum can cause
exacerbations of SLEexacerbations of SLE
 Women with serious SLE should beWomen with serious SLE should be
counseled against pregnancycounseled against pregnancy

• Psychosocial issuesPsychosocial issues
 Counsel patient and family that SLECounsel patient and family that SLE
has good prognosishas good prognosis
 Physical effects can lead to isolation,Physical effects can lead to isolation,
self-esteem, and body imageself-esteem, and body image
disturbancesdisturbances
 Assist patient in developing goalsAssist patient in developing goals

EvaluationEvaluation
• Expected outcomesExpected outcomes
 Completion of priority activitiesCompletion of priority activities
 Verbalization of having more energyVerbalization of having more energy
 Expression of satisfaction with painExpression of satisfaction with pain
relief measuresrelief measures

• Expected outcomes (cont’d)Expected outcomes (cont’d)
 Performance of activities of daily livingPerformance of activities of daily living
without painwithout pain
 Limitation of direct exposure to sunLimitation of direct exposure to sun
and use of sunscreenand use of sunscreen
 No open skin lesionsNo open skin lesions

• Expected outcomes (cont’d)Expected outcomes (cont’d)
 Expression of satisfaction with activityExpression of satisfaction with activity
levellevel
 Pacing of activities to match level ofPacing of activities to match level of
tolerancetolerance
 Expression of confidence in ability toExpression of confidence in ability to
manage SLE over time and in homemanage SLE over time and in home
environmentenvironment

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