The document presents a case study of a 41-year-old Saudi female patient diagnosed with systemic lupus erythematosus (SLE) and chronic kidney disease (CKD), detailing her treatment journey including plasmapheresis and renal biopsy. It discusses SLE's pathophysiology, types, diagnostic criteria, and ongoing management therapies such as continuous renal replacement therapy. Additionally, it outlines pharmacological treatments, symptomatology, and nursing care approaches tailored to managing chronic pain, activity intolerance, and cardiac output issues related to SLE.

1. Systemic Lupus Erythematous (SLE)
Jamilah saad Alqahtani
CNS,MSN,BSN,RGN,OR Specialist

2. SLE
Systemic Lupus Erythematous (SLE)

3. CASE STUDY
• Aysha, 41yr old, female, Saudi, admitted in A/E on 19/2/2014 with
C/O SOB, diarrhea, loss of appetite, medical diagnosis as CKD and SLE.
Treatment started with 5 session of plasmaphersis in A/E and one
more last week .than pt shifted to 34A and renal biopsy done on
24/2/2014 her HB was 6.9gm% 3unit of PRBC received. Cyelospores
given on 27/2/2014.
• On 01/3/2014 at 0800h PT develop SOB 2l of O2 via nasal cannel
started. 100% NRBM desalinate after that PT stable. Haemodyalysis
done. On 01/3/2014 at 1600 after dialysis pt develop SOB and coded
.elective intubation done. PT shifted to CCU at 1830 , central line
inserted. Hematology, nephrology suggested after TPE CRRY with
CVVH mode IVIG 25gm ¼ after TPE, calcium gluionate 25gm inj during
TPE, factor VII 2doses in 3 hrs inleira stat. PT head continuous oral,
nasal and endotrache bleeding .HB 5.9 2unit PRBC gansfused at 2215
CRRT started 2400h terminated. TPE started and terminated on
0215h. At 0015 hypotension norepinphrine inj started, for GI bleed
pimtoprafole 8mg/hr inj started.
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4. • Received from CCU at 15:17hr for future management
plasmaphresis 81hr session done in MICU . on 2/3/14
HB 5.3 3unit PRBC , plasmaphresis 9ih session done in
3/3/2014. Left jugular double lumen inserted.
• Present problem: SLE, CKD, hypoxia, respiratory failure,
noncardiogenic pulmonary odema, intra alveolar
hemorrhage.
• On going treatment : CRRT and plasmaphresis.
• Medications: fentanel 300, madizolam, pantopazal,
insulin with hold ( because increase blood sugar level)
• Lab result : low HB 9.0, INR1.24,renal function
electrolytes up and down managed with dialysis.
• Nursing Care: ICU pt full dependent
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5. • Introduction
• Definition
• Perceptions
• Pathophyisology
• Signs and symptoms
• Risk factors
• Warning signs of SLE
• Types of SLE
• Diagnostic studies
• Treatment
• Nursing process
• Summary
• References
Out lines
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6. Introduction
The term ‘lupus’ (Latin for ‘wolf’) was first used
during the Middle Ages to describe erosive skin
lesions evocative of a ‘wolf’s bite’.
Lupus is an autoimmune disease, which means
that the body's natural defense system (immune
system) attacks its own tissues instead of
attacking foreign substances like bacteria and
viruses. This causes inflammation which can
causes swelling, pain, and tissue damage
throughout the body.
Prevalence: Almost 90% of all cases occur in
women. Overall, SLE affects women eight times
more often than men.
jamilah saad alqahtani 6

7. • SLE is characterized by the
production of unusual antibodies
in the blood.
• The cause(s) of SLE is unknown,
however, heredity, viruses,
ultraviolet light, and drugs all may
play some role.
• Genetic factors increase the
tendency of developing
autoimmune diseases, and
autoimmune diseases such as
lupus, rheumatoid arthritis, and
autoimmune thyroid disorders.jamilah saad alqahtani 7

8. Pathophysiology of SLE
Immune responses against endogenous nuclear
antigens are characteristic of SLE.
Autoantigens released by apoptotic cells are
presented by dendritic cells to T cells leading to
their activation.
Activated T cells in turn help B cells to produce
antibodies to these self-constituents by
secreting cytokines such as interleukin 10
(IL10).
The pathogenesis of SLE involves a multitude of
cells and molecules that participate in
apoptosis, innate and adaptive immune
responses.
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9. jamilah saad alqahtani 9

10. Locally produced cytokines, such as IFNα and
tumour necrosis factor (TNF), contribute to
affected tissue injury and inflammation. These
mediators, together with the cells producing
them (macrophages, leucocytes, dendritic cells
and lymphocytes), are the subject of
investigation as potential therapeutic targets in
lupus.
Vascular damage in SLE has received accelerate
atherosclerosis. cytokines, such as IFNα, impair
endothelial function and decrease the
availability of endothelial precursor cells to
repair endothelial injury.
Pathophysiology of SLE
jamilah saad alqahtani 10

11. Types of lupus
There are several types of lupus. The
main types are:
1. Discoid lupus erythematous is a
mild form of lupus that only affects the
skin. It causes symptoms such as: red,
circular, scaly marks on the skin that
can thicken and scar, hair loss,
permanent bald patches
DLE can usually be successfully
controlled using medication and by
avoiding exposure to direct sunlight.
DLE usually only affects the skin.
jamilah saad alqahtani 11

12. Types of SLE
2. Drug-induced lupus: There are over 100
medications known to cause lupus-like side
effects in certain people.
Stopping the course of medication will usually
help resolve symptoms of drug-induced lupus.
E.g. Anti-seizure medications.
3. Systemic lupus erythematous: is a type of lupus
that can affect any body tissue and organ.
The symptoms of SLE can range from mild to
severe. Many people will experience long periods
of time with few or no symptoms before
experiencing a sudden flare-up where their
symptoms are particularly severe.
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13. SIGNS AND SYMPTUMS
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14. Diagnosis of lupus
The following are 11 criteria used for diagnosing systemic
lupus erythematosus:
1. Malar (over the cheeks of the face) "butterfly" rash
2. Discoid skin rash (patchy redness with
hyperpigmentation and hypopigmentation that can
cause scarring)
3. Photosensitivity (skin rash in reaction to sunlight
[ultraviolet light] exposure)
4. Mucous membrane ulcers (spontaneous sores or ulcers
of the lining of the mouth, nose, or throat)
5. Arthritis (two or more swollen, tender joints of the
extremities)
6. Pleuritis or pericarditis (inflammation of the lining tissue
around the heart or lungs, usually associated with chest
pain upon breathing or changes of body position)
7. Kidney abnormalities (abnormal amounts of urine
protein or clumps of cellular elements called casts
detectable with a urinalysis)
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15. Diagnosis of lupus
8. Brain irritation (manifested by seizures
[convulsions] and/or psychosis, referred
to as "lupus cerebritis")
9. Blood-count abnormalities: low (WBC)
or red (RBC), or platelet count on routine
complete blood count testing)
10. Immunologic disorder
11. Antinuclear antibody (positive ANA
antibody testing [antinuclear antibodies
in the blood])
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16. TREATMENT
PHARMACOLOGY:
• NSAIDs – Acetaminophen(Tylenol)
Use to control mild to moderate pain, fever, and
various inflammatory conditions, such as
rheumatoid arthritis and osteoarthritis, have
analgesic, antipyretic,
• CORTICOSTEROIDS – Prednisone
Take with food or milk to decrease the risk of
gastric ulcer, take medication at the same time
each day, don’t stop taking suddenly.
• ANTI-MALARIAL - Hydroxychloroquine
is used as an adjunct to corticosteroid therapy in
the treatment of discoid lupus erythematosus &
systemic lupus erythematosus.
jamilah saad alqahtani 16

17. Treatment
• Continuous Renal Replacement Therapy (CRRT)
If your patient is critically ill with acute kidney injury (AKI), CRRT is one
of the primary therapies. The goal of any continuous renal
replacement therapy (CRRT) is to replace, as best as possible, the
lost function of kidneys. CRRT provides slow and balanced fluid
removal that even unstable patients - those with shock or severe
fluid overload - can more easily tolerate. Both average and smaller
size patients can undergo CRRT therapy and it can be adapted
quickly to meet changing needs
jamilah saad alqahtani 17

18. Treatment
• Plasmaphersis:
Plasmapheresis is a term used to refer to a broad range of procedures in which extracorporeal
separation of blood components results in a filtered plasma product.[1, 2] The filtering of plasma
from whole blood can be accomplished via centrifugation or semipermeable membranes.[3]
Centrifugation takes advantage of the different specific gravities inherent to various blood
products such as red cells, white cells, platelets, and plasma.[4] Membrane plasma separation uses
differences in particle size to filter plasma from the cellular components of blood.[3]
• Traditionally, in the United States, most plasmapheresis takes place using automated centrifuge-
based technology.[5] In certain instances, in particular in patients already undergoing hemodialysis,
plasmapheresis can be carried out using semipermeable membranes to filter plasma.[4]
• In therapeutic plasma exchange, using an automated centrifuge, filtered plasma is discarded and
red blood cells along with replacement colloid such as donor plasma or albumin is returned to the
patient. In membrane plasma filtration, secondary membrane plasma fractionation can selectively
remove undesired macromolecules, which then allows for return of the processed plasma to the
patient instead of donor plasma or albumin. Examples of secondary membrane plasma
fractionation include cascade filtration,[6] thermofiltration, cryofiltration,[7] and low-density
lipoprotein pheresis
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19. Physical examination
Skin:
Color: pale, mottled, flushed
Temp.: warm
Moister; WNL
Condition; Malar or
Butterfly rash, Discoid Rash
in all of the body, itching,
skin color variation,
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20. PHYSICAL EXAMINATION
Head:
Vision: normal, reactive to
light , pupil size 3, Blurred
vision, sclera yellow due to L
Hb.
Hearing; normal, pain in LT
ear
Mouth: painless Oral
ulceration,
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21. Neuromuscular:
Alert/oriented, lethargic, moves
extremities limited in RT leg.
RA in the knees can cause excessive
swelling and pain, warmth and tenderness
in the knee, and difficulty with motion.
toes to contract in a “claw toe” deformity.
Hallux valgus occurs in the great toe which
leads to changes in weight shifting and
gait, and possibly pain in other areas of
the lower extremity due to gait
compensation.
Tingling & numbness in the feet
jamilah saad alqahtani 21

22. CRANIAL NERVE (CN) FUNCTION
CN I – olfactory [√ ] intact [ ] impaired [ ] unknown
CN’s II-III-IV-VI– optic, oculomotor, trochlear,
abducens (eye exam)
CN V– trigeminal (facial sensory & jaw motor) [√]
intact [ ] impaired
CN VII - Facial (symmetry in face expressions & taste)
[√] intact [ ] impaired
CN VIII – Acoustic (hearing exam)
CN IX – Glossopharyngeal (taste at back of tongue) [√
] intact [ ] impaired
CN X - Vagus (palate movement, “ah” and vocal motor
[√] intact [ ] impaired
CN XI – Spinal Accessory (head motion & shrug) [√]
intact [ ] impaired
CN XII – Hypoglossal (tongue position & motor) [√ ]
intact [ ] impaired
SENSORY FUNCTION
Touch [√ ] intact [ ] impaired
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23. 1987 ACR Classification Criteria for Rheumatoid Arthritis
Patients must have four of the seven criteria:
• Morning stiffness lasting at least 1 hour*
• Swelling in three or more joints*
• Swelling in hand joints*
• Symmetric joint swelling*
• Erosions or decalcification on x-ray of hand
• Rheumatoid nodules
• Abnormal serum rheumatoid factor
*must be present at least six weeks
MOTOR FUNCTION
[ ] impaired coordination [√ ] fine motor skills impaired due to deformity in
the metaphalengeal
[ ] balance maintained while standing with eyes closed [√ ] loss of balance
immediate
REFLEXES
patellar reflex: [ ] 0: no response [√] 1+ low (normal with slight contraction
[ ] 2+ normal, visible muscle twitch and extension of lower leg [ ] 3+ brisker
than normal [ ] 4+ hyperactive, very brisk
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24. Cardiovascular
S1, S2 presence, flat neck vein
palpable radial pulse
No presence of edema on scale 0
capillary refill < 3 seconds
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25. Respiratory
Auscultated breath sounds:
[√] vesicular sounds at periphery
[√] bronchovesicular sounds between
scapulae or 1st – 2nd intercostal space
lateral to sternum
[√] bronchial sounds over trachea
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26. Gastrointestinal
[√ ] constipation: enema given
[√ ] distention
Bowel Sounds:
[√ ] Present in all quadrants
[√ ] poor appetite or loss of
appetite
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27. 1. Chronic pain r/t actual tissue damage
• Assess the pain level on pain scale.
• Assess the patient for pain presence routinely at frequent
intervals, often at the same time as vital signs are taken,
& during activity & rest.
• Assess pain location, characteristics, intensity with every
report of pain.
• Determine the patient current medication use. Obtain an
accurate & complete list of medications are taken.
Accurate medication reconciliation can prevent
withdrawal & errors associated with incorrect medication,
dosages, drug-drug interactions & toxicity. History taken
will understand what medication have been tried & were
its effective or not in treating the patient pain (APS, 2008;
Krenzischek, 2008; The Joint Commission (TJC), 2009).
Nursing diagnosis & intervention
jamilah saad alqahtani 27

28. 1. Chronic pain r/t actual tissue
damage
• Manage persistent or chronic pain using
multimodal approach. The most effective
treatment for all pain is a multimodal &
balanced approach that combines both
pharmacologic & non-pharmacologic
strategies(Gordon et all, 2004).
• Question the patient about any disruption in
sleep. EB. Client with low back pain had
significant loss of sleep(Marin, Cyhan, & Miklos,
2006).
Outcome:
Decrease pain as evidenced by perform necessary
activities at a pain level less than or equal to the
comfort-function goal. jamilah saad alqahtani 28

29. 2. Activity intolerance r/t fatigue.
• Assess severity of fatigue on a scale of 0 to
10, assess frequency(No. of days/week &
time of day), activities & symptoms
associated with increased fatigue(e.g.
pain), interference with social & role
function, times of increase energy, ability to
concentrate, mood, & usual pattern of
activity.
• multidimensional fatigue inventory. EBN:
these measures have shown the ability to
detect changes in fatigue over
time(Whittehead, 2009).
jamilah saad alqahtani 29

30. • Evaluate adequate nutrition & sleep.
Encourage the patient to get adequate rest,
avoid caffeine in late afternoon or evening,
eat a well-balanced diet with at least 8
glasses of water a day.
• Identify physiological causes of fatigue that
could be treated, such as, anemia, pain,
electrolyte imbalance, hypothyroidism.
Outcome:
Alleviate fatigue as evidenced by performance
of usual routine activity.
2. Activity intolerance r/t fatigue.
jamilah saad alqahtani 30

31. 3. Decrease cardiac output r/t cardiac
dysfunction.
• If chest pain is present, have patient lie down, monitor
cardiac rhythm, give oxygen, check vital signs.
Assessment of the patient with acute coronary
symptoms is critical because the incidence of VF is 15
times greater during the first hour after symptoms of
an acute MI(Newberry, 2003).
• Assess pulse oximetry regularly, using a forehead
sensor if needed. EBN: in a study that compared oxygen
saturation values of arterial blood gases to various
sensors, it was found that the forehead sensor was
significantly better than the digit sensor for accuracy in
patients with low CO, while being easy to use & not
interfering with patient care(Fernandez et al, 2007).
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32. • Apply graduate compression stocking as ordered.
Ensure proper fit by measuring accurately. Remove the
stocking at least twice a day, then reapply. Assess the
condition of the extremity frequently. EB: graduate
compression stocking, alone or used in conjunction
with other prevention modalities, help promote
venous return & prevent deep vein thrombosis in
hospitalized patients(Amarigiri & Lees, 2005).
• Observe for chest pain or discomfort, note location,
radiation, severity, quality, duration, associated
manifestations such as nausea, also note precipitating
& relieving factors. Chest pain/ discomfort is generally
indicative of an inadequate blood supply to the heart,
which can compromise CO.
3. Decrease cardiac output r/t cardiac
dysfunction.
jamilah saad alqahtani 32

33. • Monitor bowel function. Provide stool softeners as
ordered. Caution patient not to strain when defecating.
Decrease activity can cause constipation, as well as pain
medication. Straining when defecating that result in the
valsalva maneuver can lead to dysrhythmia, decrease
cardiac function.
• Have patient use a commode for toileting & avoid bedpan.
Getting out of bed to use a commode doesn't stress the
heart any more than staying in bed to toilet. In addition
getting out of bed minimize complication of immobility
(Winslow, 1992).
• Weigh patient at same time daily(after voiding). EB:
clinical practice guidelines states that weighing at the
same time daily is useful to assess the effect of diuretic
therapy(Jessup et al, 2009). Use the same scale if possible.
Daily weight is a good indicator of fluid balance. Increase
weight & severity of symptoms can signal decrease
cardiac function with retention of fluids.
3. Decrease cardiac output r/t cardiac
dysfunction.
jamilah saad alqahtani 33

34. 3. Decrease cardiac output r/t cardiac dysfunction.
• Serve small, frequent, Na restricted, low cholesterol meals.
Na restricted diet help decrease fluid volume excess. low
cholesterol diet help decrease atherosclerosis, which cause
coronary artery disease. Patient with cardiac disease tolerate
smaller meals better because they require less cardiac output
to digest. EBN: a study that assessed gender differences in
dietary Na restriction found that women were more likely
than men to recognize Na buildup as fluid retention, & had a
better understanding of what to take for a low Na diet & were
more adherent to the restriction(Chung et al, 2006).
• Serve only small amount of coffee or caffeine-contaning
beverages (no more than 4 cups/24h) if no resulting
dysrhythmia. EBN: a review of studies on caffeine & cardiac
arrhythmias conclude that moderate caffeine consumption
dose not increase the frequency or severity of cardiac
arrhythmia(Schneider, 1987; Myers & Harris, 1990; Hogan,
Hornick, & Bouchoux, 2002).
jamilah saad alqahtani 34

35. 4. Impaired skin integrity r/t presence of skin
lesions
• Assess site of skin impairment & determine cause(e.g.
acute or chronic wound, dermatological lesion, pressure
ulcer, skin tear).
• Monitor site of skin impairment at least once a day for
color changes, redness, swelling, warmth, pain, or other
signs of infection. Pay special attention to the high-risk
areas such as bony prominence, skinfolds, the sacrum &
heels. Systemic inspection can identify impeding
problems early(Ayello & Braden, 2002; Ayello,
Baranoski, & Salati, 2006).
• Monitor patient continence status, & minimize exposure
of skin impairment & other areas of moisture from
incontinence, perspiration, or wound drainage. EBN:
moisture from incontinence contributes to pressure
ulcer development by macerating the skin(WOCN, 2003,
2009).
jamilah saad alqahtani 35

36. • Avoid massaging around the site of skin impairment
& over bony prominences. Researches suggests that
massage may lead to deep-tissue trauma (Panel for
prediction & prevention of pressure ulcers in adult,
1992).
Outcome:
Skin integrity as evidenced by no lesions presence
between skin folds.
4. Impaired skin integrity r/t presence
of skin lesions
jamilah saad alqahtani 36

37. 5. Risk for infection r/t PICC access
• Observe & report signs of infection such as redness,
warmth, discharge, & increase body temp especially
around PICC.
• Note & report laboratory values such as WBC
• Careful wash & pat dry skin, including skinfolds areas. Use
hydration & miniaturization on all at-risk surface.
Dermatitis is a common, chronic skin condition than can
be managed in most clients by prescribing avoidance
measures, good skin care, & conservative topical
medications (Mack, 2004).
• Encourage fluid intake. Help thins secretion & replace
fluid lost during fever (CDC, 2004).
• Follow standard precautions & wear gloves during any
contact with blood, mucus membrane, non-intact skin
jamilah saad alqahtani 37

38. • Use clean gloves for all high-risk hospitalized
patients. EB: this study demonstrate the
effectiveness of using clean gloves to prevent
cross-contamination of all multi-drug resistance
health care-aquired pathogens (Safdar et al, 2006).
• Ensure appropriate hygienic care with hand
washing, bathing, oral care, & perineal care. Daily
shower or bath can help to reduce the number of
bacteria on the patient skin. The oral cavity is a
common site of infection (Coughlan & Healy,
2008).
Outcome:
Patient will be free from infection as evidenced by
clean wound around PICC, no fever, free from
symptoms of infection.
5. Risk for infection r/t PICC access
jamilah saad alqahtani 38

39. 6. Self-care deficits related to
contractures, or loss of motion
Goal: Achieves self-care independently or with
the use of resources
Intervention:
• Identify self-care deficits and factors that interfere
with ability to perform self-care activities.
• Provide appropriate assistive devices.
• Reinforce correct and safe use of assistive devices.
• Allow patient to control timing of self-care
activities.
• Explore with the patient different ways to perform
difficult tasks.
jamilah saad alqahtani 39

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chronic low back pain, Am J Phys Med Rehabil 85(5):430-435, 2006
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41. ANY QUASTIONS
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42. THANK YOU
jamilah saad alqahtani 42