Systemic Lupus Erythematosus (SLE)

 Chronic multisystem inflammatory disease

 Inflammatory process going on in multisystem over long periods of time.
 Associated with abnormalities of immune system
 One of the primary symptoms are arthritis, pain and stiffness
 Results from interactions among genetic, hormonal, environmental, and immunologic
factors
 Exacerbations and remissions
 Flare up where symptoms get aggravated (exacerbation)
 Going back to the base line (remission)
 Affects the
 Skin
 Joints
 Serous membranes…Pleuritis (lungs) and Pericarditis (heart)
 Renal system
 Hematologic system
 Neurologic system

 SLE affects 4-250 persons per 100,000. Worldwide 250 people per population…Prevalent
problem
 Most cases occur in women of childbearing years
 African, Asian, Hispanic, and Native Americans 3x more likely to develop than whites

Etiology and Pathophysiology

 Etiology is unknown
 Most probable causes
 Genetic influence
 Over 100 genes may be involved, familial
 Hormones: abnormal estrogen metabolism
 Pregnancy and menstruation
 The disease processes tend to show up when girls first get their period or
the first time they get pregnant.
 Environmental factors
 UV light, stress, chemicals
 Pt go out in the sun and get body rash can be an indication of disease
process
 Certain medications
 Hydralazine…antihypertensive (vasodilator, lower blood pressure),
 Procainamide…anti-rhythmics for ventricular dysrhythmias

 Autoimmune reactions directed against constituents of cell nucleus, DNA

 The immune system get activated and gets directed against its own cells, in
particular the DNA get involved or affected.
 Once we have the immune system activated we have stimulation of B cells ands
T cells (help fight infection)
 Antibody response related to B and T cell hyperactivity
 Activation of antibody~antigen complexes…complexes can clog up the cell membrane
 Fight against body’s own cells
 Not removed by usual phagocyte system
 Complexes deposit in cell membranes/tissues
 Kidneys, heart, skin, brain, joints
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  Leads to systemic manifestations

Clinical Manifestations

 Ranges from a relatively mild disorder to rapidly progressing, affecting many body systems
 Most commonly affects the skin/muscles, lining of lungs, heart, nervous tissue, and kidneys
 Dermatologic
 Cutaneous vascular lesions…open lesions on the skin
 Butterfly rash…over cheek bone and bridge of nose (malar…cheek bone)
 Oral/nasopharyngeal ulcers
 Alopecia…hair loss
 Musculoskeletal
 Polyarthralgia with morning stiffness
 Arthritis
 Swan neck fingers
 Ulnar deviation…bone in the forearm
 Subluxation with hyperlaxity of joints…dislocation with loose joints
 Cardiopulmonary
 Tachypnea…increase respiration
 Pleurisy…inflammation or infection (the layer are not able to slide past each other
very easily through inhale or exhale
 Dysrhythmias
 Accelerated CAD…increased coronary artery disease at a prevalence pace
 Pericarditis…inflammation or infection of serous membrane surrounding the heart
 Renal
 Lupus nephritis
 Ranging from mild proteinuria to glomerulonephritis (renal failure)
 Primary goal in treatment is slowing the progression
 Renal failure
 Nervous system
 Generalized/focal seizures
 Peripheral neuropathy…numbness or tingling in exetremities
 Cognitive dysfunction
 Disorientation
 Memory deficits
 Psychiatric symptoms

(Raynard’s Disease…vasco occlusive disease, circulation hands or feet will camp down…
hands get cold/pale …sometimes people can loses finger tips if disease process is so bad.

 Hematologic
 Formation of antibodies against blood cells…can affect the way blood cells are
formed and function
 Anemia (RBC)…low number of circulating RBC
 Leukopenia (WBC)…low number of WBC
 Thrombocytopenia (platelets)…low
 Coagulopathy (clotting)…by can affect clotting differently, by not allowing us to clot
putting us at a higher risk of hemorrhaging or clot to well developing a blood clot

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  Anti-phospholipid antibody syndrome…the amount of cholesterol…a lot of
cholesterol buildup
 Infection
 Increased susceptibility to infections…due to WBC being low
 Fever should be considered serious

Diagnostic Studies
 No specific test to diagnose
 SLE is diagnosed primarily on criteria relating to
 Patient history
 Physical examination
 Laboratory findings
 CBC: RBC, WBC…normal values (RBC) 4.5-5.0/5.6, (WBC) 5,000-10,000
 ANA titer: antinuclear antibody (normal value is 0)…blood test measures antinuclear
antibodies, normally don’t have present…if titer is done and a value is associated
with than ANA titer is positive…associated with other autoimmune disease
 LE prep test (non-specific)…can be positive in other inflammatory condition
 Antibodies: (most specific for the SLE disease process)
 Anti-double stranded DNA antibody
 Anti-Smith Antibody
 BUN/Creatinine…This disease can affect kidney function…elevated lab value
 ESR: erythrocyte sedimentation rate…Elevated with inflammatory disorder…use to
monitor patient treatment
 Urinalysis (UA) - Protein in urine
 Chest Xray (CXR) - Pleuritis and Pericarditis
 MRI - Neuro involvement
 ECG - (Dysrhythmias or Arrhytmias)

Collaborative Care: Drug Therapy

 NSAIDS
 Aspirin, ibuprofen
 Reduce inflammatory response in the joints
 Pain relief for muscles, joints
 Antimalarial drugs
 Hydroxychloroquine
 Inflammation associated w/ arthritis
 Suppresses part of immune response
 Can cause retinal damage…requires regular eye exams
 Used when the muscle joint arthritis type symptoms are no longer
responding to the NSAIDS

 Immunosupressive agents
 Azathioprine (Imuran), cyclophosphamide (Cytoxan) >chemotherapeutic
agents
 Aggressive therapy for renal, CNS, CV involvement
 Monitor for Side Effect: anemia, infection, malignancy
 Steroids
 Prednisone…drug of choice
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  Low-dose when NSAIDs not sufficient, higher dose with more severe
systemic involvement
 Need to taper, watch for SE (side effects)
Nursing Assessment
 Assess patient’s physical, psychologic, and sociocultural problems with long-term
management of SLE
 Assess pain and fatigue daily
 Obtain subjective and objective data
 Educate and counsel on expected issues

Nursing Diagnoses
 Fatigue  Body image
 Acute pain  Role dysfunction
 Impaired skin integrity
Planning
 Overall goals
 Have satisfactory pain relief
 Comply with therapeutic regimen to achieve maximum symptom management
 Demonstrate awareness of, and avoid activities that cause, disease exacerbation
 Maintain optimal role function and a positive self-image

Nursing Implementation
 Health promotion
 Prevention of SLE is not possible
 Promote early diagnosis and treatment
 Acute intervention
 During exacerbation, patient will become abruptly, dramatically ill
 Record severity of symptoms and response to therapy
 Observe for
 Fever pattern
 Joint inflammation
 Limitation of motion…ROM
 Location and degree of discomfort
 Fatigability…structure activity when less fatigue
 Monitor weight and I&O…due to steroid and kidney involvement
 Collect 24-hour urine sample…looking for protein
 Assess neurological status…look for changes in baseline
 Explain nature of disease
 Provide support
 Ambulatory and home care
 Emphasize health teaching
 Reiterate that adherence to treatment does not necessarily halt progression
 Minimize exposure to precipitating factors
 UV exposure
 Rest w/ regular exercise…to keep muscle strength
 avoid stress when ever we can
 Lupus and pregnancy
 Infertility can result from SLE’s regimen
 Women with serious SLE should be counseled against pregnancy
 Neonatal lupus erythematosus (NLE) may occur in infants born of women with
SLE
 Psychosocial issues
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  Counsel patient and family that SLE has good prognosis
 Physical effects can lead to isolation, self-esteem, and body image disturbances
 Assist patient in developing goals
Evaluation
 Expected outcomes
 Completion of priority activities
 Verbalization of having more energy
 Expression of satisfaction with pain relief measures
 Performance of activities of daily living without pain
 Limitation of direct exposure to sun and use of sunscreen
 No open skin lesions
 Topical steroid for open lesions
 Expression of satisfaction with activity level
 Pacing of activities to match level of tolerance
 Expression of confidence in ability to manage SLE over time and in home
environment