Nursing Diagnosis for

Nephrolithiasis
1. Acute Pain related to tissue trauma, increased ureteric contraction, edema formation.
2. Impaired Urinary Elimination related to irritation of the kidney / ureter, mechanical
obstruction, inflammation, bladder stimulation by a stone.
3. Risk for Deficient Fluid Volume related to neusea, vomiting.
4. Knowledge Deficit related to misinformation.
Expected Results:
1. Comfort the pain resolved.
2. Impaired elimination pattern is resolved.
3. No deficit fluid.
4. The client will open up requests for information.
Nursing Intervention for Nephrolithiasis
1. Observe and record the location, duration, intensity of pain distribution.
2. Explain the cause of pain.
3. Make a control gate on the back.
4. Teach relaxation techniques.
5. Give fluid intake 3000 ml - 4000 ml / day.
6. Collaborative provision of medicines.
7. Monitor intake / output.
8. Observe urination.
9. Prepare a laboratory urine.

10. Observation circumstances bladder.

11. Collaboration laboratory examination.
12. Observe and record abnormalities such as vomiting.
13. Monitor vital signs.
14. Give a diet based on the program.
15. Collaboration giving intravenous fluids.
16. Give an explanation of the disease process.
17. Explain the importance of fluid intake 3000 - 4000 ml / hr.
18. Explain about diabetes management.
19. Discuss with the client / kelguarga about the rule of treatment & types of food.
20. Instruct the client to do activity regularly.

Nursing Diagnosis for Diabetes Mellitus

1. Impaired tissue perfusion related to weakening / decreased blood flow to the area
gangrene due to obstruction of blood vessels.
2. Integrity of the tissue disorder related to gangrene in the extremities.
Nursing Intervention for Diabetes Mellitus
1. Impaired tissue perfusion related to weakening / decreased blood flow to the area gangrene
due to obstruction of blood vessels.
Goal :
Peripheral Circulation remain normal.
Result Criteria :

Palpable peripheral pulse strong and regular

The color of the skin around the wound was not pale / cyanotic

The skin around the wound felt hot.

Edema did not occur and injuries from getting worse.

Sensory and motor improvement.

Nursing Intervention :

Teach the patient to mobilize

Rational : the mobilization improves blood circulation.

Teach about the factors which can increase blood flow :

Elevate feet slightly lower than the heart (the position of elevation at rest), avoid crossing
legs, avoiding tight bandage, avoid the use of pillows, hamstrings and so forth.
Rational : to increase blood flow through so that does not happen edema.

Teach about the modification of risk factors such as :

Avoid a diet high in cholesterol, relaxation techniques, smoking cessation, and drug use
vasoconstriction.
Rational : high cholesterol can accelerate the occurrence of atherosclerosis, smoking can
cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.

Collaborate with other health team in giving vasodilators, checking blood sugar regularly
and oxygen therapy (HBO).
Rational : giving vasodilators will increase the dilation of blood vessels so that tissue
perfusion can be improved, while checking blood sugar regularly to know the progress
and state of the patient, to improve oxygenation HBO areas ulcer / gangrene.

2. Integrity of the tissue disorder related to gangrene in the extremities.

Goal : The achievement of the wound healing process.
Result Criteria :

Decreased edema around the wound.

The presence of granulation tissue.

The stench of injury is reduced.

Nursing Intervention :

Assess the wound area and state as well as the healing process.
Rational : the right assessment of the wound and the healing process will assist in
determining further action.

Treat wounds with good and true: clean wound abseptik use solution that is not irritating,
lift the rest of the bandages that stick to the wound and nekrotomi dead tissue.
Rational : treating wounds with aseptic technique, wound contamination and can
maintain the solution will damage the granulation tissue irritating tyang arise, the
remaining dressing to hamper the process of necrotic tissue granulation.

Collaboration with physicians for the administration of insulin, pus culture examination,
examination of blood sugar, giving anti-biotic.
Rational : the insulin will lower blood sugar, pus culture examination to determine the
types of germs and antibiotics, are appropriate for the medication, checking blood sugar
levels to determine the progression of the disease.

3. Impaired sense of comfort (pain) related to ischemic tissue.

Goal :
No pain / reduced pain
Result Criteria :

Patients say the pain verbally reduced / lost.

Patients can perform the methods or actions to overcome or reduce pain.

Expanding patient movement.

No cold sweat, vital signs within normal limits. (Temperature: 36 to 37.5 0C, Nadi 60 80 x / min, Blood Pressure: 100-130 mmHg, Respiratory: 18 - 20 x / min).

Nursing Intervention :

Assess the level, frequency, and reaction to pain experienced by patients.

Rational : to find out how severe pain experienced by patients.

Explain to the patient about the causes of pain.

Rational : understanding the patient about the causes of pain that occurs will reduce the
tension of patients and allows patients to be invited to cooperate in taking action.

Create a peaceful environment.

Rational : excessive stimulation from the environment will aggravate the pain.

Teach a distraction and relaxation techniques.

Rational : distraction and relaxation techniques can reduce pain felt by patients.

Adjust the position of the patient as pleasant as possible according to patient preference.
Rational : a comfortable position to help provide opportunities for relaxation in the
muscles optimally.

Collaboration with the doctor for giving analgesics.

Rational : analgesic drugs may help reduce pain patients.

Nursing Care Plan for Osteoarthritis

Nursing Assessment for Osteoarthritis
1. Activity / Rest
o Joint pain due to movement, tenderness worsened by stress on the joints, stiffness
in the morning, usually occurs bilaterally and symmetrically functional limitations
that affect lifestyle, leisure, work, fatigue, malaise.
o Limitation of movement, muscle atrophy, skin: contractor / abnormalities in the
joints and muscles.
2. Cardiovascular
o Raynaud's phenomenon of the hand (eg litermiten pale, cyanosis and redness on
the fingers before the color returned to normal.
3. Ego Integrity
o Stress factors of acute / chronic (eg, financial jobs, disability, relationship factors.
o Hopelessness and helplessness (inability situation).
o Threats to the self-concept, body image, personal identity, for example
dependence on others.
4. Food / Fluids

o The inability to produce or consume food or liquids adequately nausea, anorexia.

o Difficulty chewing, weight loss, dryness of mucous membranes.
5. Hygiene
o The difficulties to implement self-care activities, dependence on others.
6. Neurosensory
o Tingling in hands and feet, swollen joints
7. Pain / comfort
o The acute phase of pain (probably not accompanied by soft tissue swelling in the
joints. chronic pain and stiffness (especially in the morning).
8. Security
o Skin shiny, taut, nodules sub mitaneus
o Skin lesions, foot ulcers
o The difficulty in handling the task / household maintenance
o Mild fever settled
o Dryness in the eyes and mucous membranes
9. Social Interaction
o Damage interaction with family or others, the changing role: isolation.
10. Counseling / Learning
o Family history of rheumatic
o The use of health foods, vitamins, cure disease without testing
o History pericarditis, valve lesion edge. Pulmonary fibrosis, pleuritis.
Nursing Diagnosis for Osteoarthritis

1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid /

inflammatory process, Liquor joints.
2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased
muscle strength.
Nursing Diagnosis and Nursing Intervention for Osteoarthritis
1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid / inflammatory
process, Liquor joints.
Expected Outcomes :

Showing pain is reduced or controlled

Looks relaxed, to rest, sleep and participate in activities based on ability.

Following the therapy program.

Using the skills of relaxation and entertainment activity in the pain control program.

Nursing Intervention :

Assess pain; note the location and intensity of pain (scale 0-10). Write down the factors
that accelerate and signs of non-verbal pain.

Give the hard mattress, small pillow. Elevate bed when a client needs to rest / sleep.

Help the client take a comfortable position when sleeping or sitting in a chair. Depth of
bed rest as indicated.

Monitor the use of a pillow.

Help clients to frequently change positions.

Help the client to a warm bath at the time of waking.

Help the client to a warm compress on the sore joints several times a day.

Monitor temperature compress.

Give a massage.Encourage the use of stress management techniques such as progressive
relaxation bio-feedback therapeutic touch, visualization, self hypnosis guidelines

imagination, and breath control.Engage in activities of entertainment that is suitable for

individual situations.

Give the drug before activity / exercise that is planned as directed.

Assist clients with physical therapy.

2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased muscle
strength.
Expected Outcomes :
Maintain or improve strength and function of the compensation part of the body
Demonstrating techniques / behaviors that allow doing activities.
Nursing Intervention

Monitor the level of inflammation / pain in joints

Maintain bed rest / sit if necessary

Schedule of activities to provide a rest period of continuous and uninterrupted nighttime

sleep.

Assist clients with range of motion active / passive and resistive exercise and isometric if
possible.

Slide to maintain an upright position and sitting height, standing, and walking.

Provide a safe environment, for example, raise the chair / toilet, use a high grip and tub
and toilet, the use of mobility aids / wheelchairs rescue.

Collaboration physical therapist / occupational and specialist vasional.

Bronchial Asthma
Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the
respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated
resistance to airflow in the airways. Despite its most strenuous efforts, the respiratory
musculature is unable to provide sufficient gas exchange. The result is a characteristic asthma

attack, with spasms of the bronchial musculature, edematous swelling of the bronchial wall and
increased mucus secretion. In the initial stage, the patient can be totally symptom-free for long
periods of time in the intervals between the attacks. As the disease progresses, increased mucus
is secreted between attacks as well, which in part builds up in the airways and can then lead to
secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be
demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander,
dust). Although most individuals with asthma will have some positive allergy tests, the allergy is
not necessarily the cause of the asthma symptoms.
Symptoms can occur spontaneously or can be triggered by respiratory infections, exercise, cold
air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies.
The muscles of the bronchial tree become tight and the lining of the air passages become
swollen, reducing airflow and producing the wheezing sound. Mucus production is increased.
Typically, the individual usually breathes relatively normally, and will have periodic attacks of
wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow
becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is
1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the
illness. Risk factors include self or family history of eczema, allergies or family history of
asthma. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is
an allergic condition, in which the airways (bronchi) are hyper-reactive and constrict abnormally
when exposed to allergens, cold or exercise.
Nursing Care Plan for Bronchial Asthma
Nursing Assessment for Bronchial Asthma
1. Past medical history :
o Assess personal or family history of previous lung disease.
o Review the history of allergic reaction or sensitivity to the substances /
environmental factors.
o Assess the patient's employment history.
2. Activity
o The inability to perform activities because of difficulty breathing.
o The decline in the ability / improvement needs help doing daily activities.
o Sleeping in a sitting position higher.
3. Respiratory

o Dipsnea at rest or in response to activity or exercise.

o Breath worsened when the patient lay supine in bed.
o Using the drug ventilator, for example: raising the shoulders, widen the nose.
o The existence of wheezing breath sounds.
o The recurrent coughing.
4. Circulation
o The increasing blood pressure.
o There is an increasing frequency of heart.
o The color of skin or mucous membranes normal / gray / cyanosis.
o Redness or sweating.
5. Ego integrity
o Anxiety
o Fear
o Be sensitive to stimuli
o Restlessness
6. Nutrition
o

o Inability to eat due to respiratory distress.

o Weight loss due to anorexia.
7. Sosal Relations
o

o The limited physical mobility.

o Difficult to talk or stammering.

o The existence of dependence on others.

8. Sexuality
o Decrease in libido.
Nursing Diagnosis for Bronchial Asthma
1. Ineffective airway clearance related to the accumulation of mucus.
2. Ineffective breathing pattern related to decreased lung expansion.
3. Impaired nutrition less than body requirements related to inadequate intake.
Nursing Intervention for for Bronchial Asthma
1. Ineffective airway clearance related to the accumulation of mucus.
Goal :
The Way of breath effectively.
Result Criteria :

Shortness reduced

Coughing reduced

Clients can issue a sputum

Wheezing is reduced / lost.

Vital signs within normal limits.

Nursing Intervention :

Auscultation of breath sounds, record the sound of breath, for example: wheezing,
erekeis, ronchi.
Rational : Some degree of bronchial spasms occur with airway obstruction. Faint breath
sounds with expiratory wheeze (empysema), no breathing function (severe asthma).

Review / monitor respiratory frequency, record the ratio of inspiration and expiration.
Rational : Tachypnoea usually found in some degree and can be found at the reception

during the stress / the process of acute infection. Respiratory frequency can be slowed
down and elongated than the expiration of inspiration.

Assess the patient to a safe position, for example: elevation of the head does not sit on the
backrest.
Rational : Elevation head is not easier for respiratory function by using gravity.

Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary actions
to improve effectiveness cough efforts.
Rational : The cough can be settled but is not effective, especially on elderly clients,
acute pain / weakness.

Give warm water.

Rational : use of warm fluids can decrease bronchial spasms.

Collaboration based drug Spiriva indikasi.Bronkodilator 1 1 (inhalation).

Rational : Freeing airway spasm, wheezing and mucus production.

2. Ineffective breathing pattern related to decreased lung expansion.

Goal :
The pattern of effective breathing.
Result Criteria :

effective breathing pattern

The sound of normal breathing or net

Vital signs within normal limits

Coughing reduced.

Expansion of the lungs inflate.

Nursing Intervention :

Assess respiratory frequency and depth of chest expansion. Record the respiratory effort
including the use of auxiliary respiratory muscles / nasal dilation.
R / velocity usually reaches a depth of respiration varies depending on the degree of
respiratory failure. Limited chest expansion associated with atelectasis and / or chest
pain.

Auscultation of breath sounds and record sounds like crekels breath, wheezing.
R / rhonchi and wheezing accompanying airway obstruction / respiratory failure.

Elevate the head and help change the position.

R/ Sitting high enable lung expansion and eases breathing.

Observation of the pattern of coughing and secretions character.

R / alveolar congestion often result in cough / irritation.

Encourage / assist the patient in breathing and coughing exercises.

R / Can increase / number of sputum where the interference plus the lack of comfortable
ventilation and breathing effort.

Collaboration
o Provide supplemental oxygen.
o Provide additional humidifikasi eg nebulizer.
R / Maximize breath breathe and reduce labor, provide moisture to the mucous
membranes and helps thinning secretions.

Systemic Lupus Erythematosus

Understanding how to prevent and treat flares helps people with SLE maintain
better health.

By Susan Fralick-Ball, PsyD, MSN, RN

Print Article

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ADVANCE, click here.
Learning Scope #430
1 contact hour
Expires April 19, 2015
You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and
certificate are available immediately after taking the online test. 2) Send the answer sheet
(or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of

Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30
days to receive certificate or notice of failure. A certificate of credit will be awarded to
participants who achieve a passing grade of 70% or better.
Merion Matters is an approved provider of continuing nursing education by the
Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the
American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered
Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this continuing education offering is to provide the latest information to nurses
about systemic lupus erythematosus (SLE). After reading this article, you will be able to:
1. Recognize the most common symptoms of SLE.
2. Explain the potential risks and complications associated with SLE.
3. Identify the diagnostic testing methods for SLE.
The author has completed a disclosure form and reports no relationships relevant to the
content of this article.
Systemic lupus erythematosus (SLE) is a complex, chronic, "overactive" autoimmune disease
associated with potentially considerable morbidity and poor health-related quality of life. The
disease itself is generally not fatal, but multiple complications in other systems may contribute to
mortality.
It is characterized by both acute and chronic inflammation of a variety of tissues throughout the
body (skin, heart, lungs, kidneys, joints, nervous system) due to the production and pathogenesis
of autoantibodies. The most common type of autoantibody that develops in people with SLE is
an antinuclear antibody (ANA) since it reacts with parts of the cell's nucleus. A mutation in a
gene that could disrupt the body's cellular waste disposal (DNase1) may be involved in the
origination of SLE. T-cells are one of the lymphocytes responsible for production and secretion
of various cytokines (cell-signaling proteins) controlling the duration and severity of a person's
immune response.1
In the U.S., estimates show 15-50 people per 100,000 in the population have SLE, and it is eight
times more common in women than men. The disease can affect all ages but most commonly
begins from ages 20 to 45. Research shows SLE is somewhat more frequent in blacks, Hispanics,
Native Americans and people of certain Asian descents (Chinese and Japanese). Blacks and
Hispanics are more likely to have active disease with multiple organ involvement.

The causes still elude physicians, yet it is thought to be associated with heredity, viruses,
ultraviolet light exposure and some drugs. SLE is characterized by periods of exacerbations of
illness, called flares, and periods of remission. Understanding how to prevent and treat flares
helps people with SLE maintain better health.
Other Forms of Lupus
Discoid lupus is a form of lupus dermatitis that can be isolated to the skin, without internal
disease. The dermatitis consists of a red, raised rash that appears on the face, scalp or elsewhere.
The raised areas may become thick and scaly and may cause scarring. The rash may last for days
or years and may recur. Approximately 5%-10% of discoid lupus progresses to SLE.
Acute cutaneous lupus erythematosus (ACLE) refers to a typical cheek and forehead eruption in
a butterfly pattern localized to the central portion of the face and/or a more generalized
maculopapular (raised) eruption representing a photosensitive dermatitis. The condition has a
strong association with SLE.2,3
Drug-induced lupus is caused by reaction to medication. Some common medication reactions
come from some antiepileptic medications, antihypertensives, antibiotics and antifungals, thyroid
medications and oral contraceptives. Symptoms are similar to those of SLE (arthritis, rash, fever
and chest pain), and they typically remit when the drug is stopped. The kidneys and brain are
rarely involved.4
Symptoms of SLE
Common symptoms of lupus include:
painful and/or swollen joints and muscle pain over multiple areas
unexplained fever
red rashes, most commonly on the face
chest pain upon deep breathing (pleuritis), myocarditis (inflamed heart muscle), endocarditis
(inflammation of the inside lining of the heart chamber and the heart valves)
unusual hair loss (alopecia)
pale or purple fingers or toes from cold or stress (Raynaud's phenomenon), vasculitis,
arteriosclerosis
sensitivity to sunlight (photophobia)
lower extremity and/or periorbital edema
mouth ulcers
swollen glands
extreme fatigue
headaches, dizziness, depression, memory and visual disturbances, seizures, stroke, behavioral
changes
anemia, thrombocytopenia, leukopenia, blood clots

Fatigue
Fatigue is a frequent and pervasive problem with multiple adverse consequences for patients
with SLE. A total of 53%-80% of SLE patients identify fatigue as one of their primary
symptoms, resulting in decreased quality of life and increased risk of work disability and
healthcare costs.5 Some factors associated with the fatigue include decreased aerobic capacity;
obesity; sleep-wake disturbances and non-restorative sleep; depression; suboptimal vitamin D
levels; and pain, coexisting fibromyalgia, thyroid disease and anemia.
Thrombosis
Rarely, lupus patients can develop very serious, even life-threatening complications of blood
clotting, (stroke, heart attack, pulmonary embolism). Most physicians and researchers focus on
the role of antiphospholipid antibodies (aPL) as the most important risk factor for thrombosis in
lupus. aPL refers to an autoimmune, hyper-coagulable state caused by antibodies forming against
cell membrane phospholipids that provoke blood clots in both arteries and veins.6 aPL can be
complicated by thrombocytopenia (low platelet count) and valvular heart disease.
Potential Symptoms & Complications With SLE
An estimated one-third of people with lupus will develop nephritis that requires medical
evaluation and treatment. Lupus nephritis is an important and potentially serious symptom of
lupus, yet with few signs of a more typical form of kidney disease. Proteinuria from lupus
nephritis may lead to lower extremity edema and weight gain. The clinical path of lupus nephritis
is highly variable and abnormal findings in urine studies may persist over time.7 Chronic renal
failure is possible.
Chronically low levels of vitamin D appear in many pre-SLE and identified SLE patients. There
appears to be a destructive immune marker related to the low vitamin D levels. Low vitamin D
also may result from necessary sun avoidance or perhaps to chronic use of steroids or
hydroxychloroquine (quinine treatment), or that many lupus patients are not taking vitamin D
supplements. It is now suggested that SLE patients take additional vitamin D as part of their
ongoing treatment.8
Pregnancy and infant complications can be prevented and treated with advances in the
understanding of SLE and better treatment options. Although this is true, all lupus pregnancies
are considered high risk and are carefully monitored. The types of pregnancy complications may
include: preeclampsia due to maternal-fetal tissue immune response; HELLP syndrome
(hemolysis of red blood celles, elevation of liver enzymes and low platelets); antiphospholipid
antibodies (lupus anticoagulant, anticardiolipin antibodies and antibodies to B2 glycoprotein I)
that can interfere with the function of the placenta; intrauterine growth restriction; impaired renal
function; lupus flares; and pre-term delivery and/or fetal loss.9 If the mother produces and passes
autoantibodies to the fetus via placental route, the child may develop a form of SLE. This is rare
and often manifests in neonatal cardiac, skin and liver difficulties.

Psychosis in SLE can be found (up to 5%) as a secondary effect from medication and/or
inflammation of brain tissue, increased intracranial pressure or cerebral thrombosis.
Neuropsychiatric systemic lupus erythematosus (NPSLE) is based upon what is already known
of the pathogenesis of the disease: autoantibodies, microvascular disease and the production of
inflammatory mediators (i.e., cytokines). Even after scientific exploration, it is very unlikely a
single biomarker will reliably predict all neuropsychiatric events. Stroke, headaches and seizures
also can be part of the NPSLE profile. Careful treatment often rests with steroids and
immunosuppressants, although these drug categories can cause psychosis as toxic side effects.
Infections
Infections are one of the most common causes of morbidity, hospitalization and death in patients
with SLE.10
Bacterial infections make up the majority of reported infectious complications in patients with
SLE. The most frequent types of infection are respiratory, urinary tract and soft tissue infections.
Prompt treatment of any identified or suspected infection is recommended. Basic hygiene and
sanitation, including frequent hand washing, are the cornerstones of prevention of many
infectious diseases. Careful use of immunosuppressive therapy may lessen infection risk, and
antimalarial medication may have protective effects against new infections.
Varicella-zoster virus (shingles or herpes zoster) is one of the most commonly reported viral
infections in SLE. Herpes zoster may result in widespread disease in patients with SLE or may
be complicated by superinfection and postherpetic neuralgia. It tends to be a late complication,
usually appearing five years after SLE diagnosis and commonly during periods of inactive or
mild SLE disease activity. Risk factors for herpes zoster include renal disease, concurrent or
prior malignancy, and azathioprine and cyclophosphamide (immunosuppressant) use. There are
currently no clear recommendations on the administration of the herpes zoster vaccine in patients
with SLE, but it should be offered to patients over age 60 with special attention to timing in
patients who may be treated with high-dose prednisone or other immunosuppressants.
Human papillomavirus (HPV) is a common viral infection in patients with SLE. Women with
SLE have a threefold increase in the rate of abnormal cervical cytology smears compared with
the general population. Prophylaxis with the vaccine is offered even though recommendations for
use are not forthcoming.
The annual incidence of influenza in the general population is under 20%; however, the rate of
infection in SLE patients is not well defined. The vaccine is preventative for many flu strains, yet
less so with immunosuppressive diseases. The influenza vaccine has been shown to cause an
increase in autoantibody formation in some patients; however, this does not translate into clinical
flares of lupus. Given the risk of potentially more severe presentations of influenza in patients

with SLE, yearly vaccination is recommended.

Diagnostics: Typical & Differential
As healthcare providers, we need to look to diagnose this disease, yet also rule out other disease
processes that mimic or confuse the diagnostic picture of the patient. Here are some of the
essential diagnostic indicators you will need to address:
personal and family medical history
complete physical examination
laboratory tests:
* complete blood count
* erythrocyte sedimentation rate
* urinalysis
* blood chemistries
* complement levels
* anticardiolipin antibody test
* skin biopsy
* kidney biopsy.
Commonly used blood tests in the diagnosis of SLE are:
antinuclear antibody test (ANA) to determine if autoantibodies to cell nuclei are present in the
blood
anti-DNA antibody test to determine if there are antibodies to the genetic material in the cell
anti-Sm antibody test to determine if there are antibodies to Sm, which is a ribonucleoprotein
found in the cell nucleus
serum (blood) complement test to examine the total level of a group of proteins which can be
consumed in immune reactions
complement proteins C3 and C4 test to examine specific levels.
The classic finding of a low C-reactive protein level with an elevated erythrocyte sedimentation
rate or plasma viscosity is found in approximately 40% of patients with SLE. In previously
undiagnosed patients thought to have SLE, the principal diagnostic study is the ANA test.1
Although many rheumatologists consider this test to be 100% sensitive for diagnosis, a positive
ANA result alone is not sufficient for diagnosis since positive test results are seen in other
autoimmune conditions and in a certain percentage of the general population (especially the
elderly). An autoantibody panel should be checked for related pathogenic antibodies.
Researchers have identified anti-double-stranded DNA antibodies and complement C3 blood
constituents as biomarkers for flares, meaning flares now can be predicted. Also found is that
moderate doses of prednisone can prevent flares in people having these biomarkers.6
Lupus anticoagulant is the strongest test to determine the risk of thrombosis in SLE-

antiphospholipid antibodies. The presence of lupus nephritis and Raynaud phenomenon strongly
predicts thrombosis. These findings help to identify patients who may benefit from prophylactic
therapy.
Neurodiagnostic evaluation supports magnetic resonance imaging over computed tomography
scanning, because subtle areas of ischemia may be seen with greater sensitivity. The most
common findings with either study are varying sizes of ischemic zones of cortical or subcortical
infarcts, according to the size of vessel involved and the mechanism of stroke. A clinical
diagnostic problem occurs when the MRI reveals multiple, small signal intensities in the white
matter, making it difficult to distinguish between multiple sclerosis and SLE.
Electroencephalography may be helpful to confirm the focal point of an apparently diffuse
encephalopathy in patients with SLE. EEG is most useful for patients with seizures whose cases
are difficult to manage.
When embolic stroke occurs in patients with proven or suspected SLE, echocardiography is
obligatory to assess for valvular and other intracardiac lesions. Cardiac emboli also remain the
most likely cause of non-embolic stroke syndromes of SLE patients. Transesophageal
echocardiography may be helpful in select cases.
Muscle weakness in patients with SLE may result from inflammatory myopathy, medicationinduced myopathy, neuromuscular junction dysfunction, neuropathies or from other
musculoskeletal disturbances. Electromyography may distinguish inflammatory vs. noninflammatory myopathy. Peripheral nerve dysfunction in SLE presents as single or multiple
nerve disturbance, often with sensory and motor symptoms. The typical findings of each of these
conditions may be demonstrated on nerve conduction studies.
Nerve biopsy may be helpful in determining an initial diagnosis of active vasculitis. Muscle
biopsy may provide the only reliable differentiation between inflammatory and medicationinduced myopathy.
Treatment
There is no cure for SLE, yet many medications can slow and amend some symptoms. Treatment
of SLE should be provided in cooperation with a consulting rheumatologist. Therapeutic
intervention depends on the severity of an acute attack. NSAIDs and other symptomatic agents
are used for less-threatening symptoms.
Corticosteroids are used in low-dose oral, high-dose oral or high-dose IV regimens, according to
the severity of potential organ damage. Previous steroid therapy may provoke an adrenocortical
deficiency state, thus complicating the course of SLE with potential problems in blood pressure,
glucose, water and electrolyte regulation. Stepped medication approach is performed in lupus
nephritis because of its frequency, severity and quantifiable improvement or deterioration, but

the same treatment approaches are generally applied to other organ systems, including the central
and peripheral nervous systems and muscular disease.11,12
If there is mild disease or symptoms that affect quality of life without organ-threatening disease,
the following may be prescribed:
acetaminophen or NSAIDs, often in combination with antimalarial drugs
antimalarial drugs such as hydroxychloroquine (e.g., Plaquenil)
low-dose corticosteroids and/or topical corticosteroid creams or ointments
sunscreens, sun block and topical steroid creams for skin rashes or photophobia.13
If there is more severe disease, the following may be prescribed:
corticosteroids, such as prednisone
immunosuppressive medicines, such as azathioprine, belimumab, cyclophosphamide,
mycophenolate mofetil or methotrexate11-13
anti-B cell therapy, such as rituximab
If there has been arterial or venous thrombosis or if the patient has antiphospholipid antibody
syndrome, an anticoagulant may be prescribed (e.g., aspirin, warfarin).
Treatment and prevention recommendations include:
yearly influenza shot
pneumococcal vaccination (every five years)
regular pap smears to screen for cervical dysplasia caused by HPV (there are currently no
recommendations or data regarding the use of the HPV vaccine in patients with SLE outside the
recommendations for the general population)
TB skin test prior to starting immunosuppressive agents and treatment with isoniazid (INH) for
patients with latent TB infection
hepatitis B serology at baseline in all patients
hepatitis C serology at baseline in patients with risk factors
HIV serology at baseline in patients with risk factors
diet/supplement recommendations include the use of fish oils, flax seed (to decrease
inflammation) and DHEA (dehydroepiandrosterone) to reduce steroid needs.
Ongoing Management of SLE
Physical therapy often is beneficial for patients with SLE. The role of the physical therapist is to
assess each patient and to determine an effective plan of care to help reduce pain, stiffness and
inflammation as well as to improve joint range of motion and functional mobility.14
Key points to keep in mind when developing a PT program for a patient with SLE include:
Exercises should be individualized. For patients with predominant joint pain or arthritis,
techniques used in rheumatoid arthritis may be helpful.

 Aerobic exercise might improve aerobic capacity in patients with mild SLE. Incorporate
isometric exercises for patients with joint inflammation, especially for the hip and knee. Isotonic
exercises can be used when joint inflammation is reduced or absent. Transfers and ambulation
activities are important for maintaining mobility.
Strengthening exercises are initiated when appropriate. Fatigue may hinder progress in some
patients.
If pain lasts for more than 60-90 minutes following activity, the exercise regimen should be
reduced in intensity and/or duration.
Proper positioning may prevent joint contractures in patients with SLE. Pillows under a painful
knee are discouraged.
Ultrasonography is a modality commonly used to provide deep heat to the affected joint, but it
should not be used in the presence of inflammation; ice is the preferred modality for inflamed
joints.
Aquatherapy is an excellent setting for exercising inflamed joints because of the buoyancy of
the water and the soothing quality of warm water.
Occupational therapy is used to help the patient regain as much of his or her functional
independence as possible despite of the problems caused by the disease. Principles of OT for
patients with SLE include:
Activities of daily living are encouraged and may require training with special equipment,
techniques and procedures.
Adaptive equipment may be necessary for patients to complete ADL tasks; some of the more
common adaptive equipment includes a raised toilet seat, splints and reach devices.
Educating the patient in joint conservation techniques is important. Although not often used
now, paraffin baths are comforting for patients with hand involvement and may improve use.
Since fatigue is so prevalent, the OT can be helpful in teaching the patient energy conservation
techniques, frequently using adaptive equipment.
A home safety evaluation may be indicated. The OT can provide recommendations for home
adaptive equipment to increase the patient's independence and safety with mobility at home.
Speech therapy can be helpful when a patient with SLE has slurred speech, difficulty
understanding speech or difficulty speaking appropriately. SLE patients with swallowing
problems also can be evaluated and treated by the speech pathologist.
Psychological therapy often is necessary when dealing with the disease itself, the multiple pain
sites, chronic fatigue, disease complications, flares or medication side effects. Many of these
patients have difficulty maintaining a regular work schedule, so financial difficulties may arise.
Psychological fragility frequently accompanies SLE with brain and body image changes,
memory loss and emotional upheaval. Due to the chronicity of SLE, psychological help may not
be an option with medical insurance coverage, thus placing a more difficult financial strain on
the patient in need of services.

Manageable Condition
Systemic lupus hails as a multifaceted disease with potentially life-threatening complications, yet
it can be well-managed for a lifetime of controllable symptoms. There are many diagnostic
indicators and treatments available to people of all ages, in varying degrees of the disease.
Scientists are finding new genetic information associated with this autoimmune disease and
trends for effective treatment emerge daily. Physicians indicate that lupus patients can live a
potentially typical life with modifications to lifestyle, diet and treatment options.
References
1. Dorner T, Giesecke C, Lipsky P. Mechanisms of Bcell autoimmunity in SLE. Arthritis Res
Ther. 2011;13(5):243.