SLE

Systemic Lupus Erythematosus

Systemic Lupus Erythematosus

a chronic (long-term) disease that can cause inflammation and pain in any part of your body. It’s an autoimmune disease, which means that your immune system — the body system that usually fights infections — attacks healthy tissue instead

Most common form of lupus; 70% of people with lupus have it. It is what people refer to as “lupus”

susceptible to common and opportunistic infections due to both inherent immune abnormalities and the use of immunosuppressive therapies

Common site for infection

Respiratory tract

Urinary tract

Skin

Death rate

25-70%

Risk factors for infections in SLE

active renal disease

overall higher disease activity

many treatments for SLE such as steroids also expose the patient to risk for infections

• antimalarial agents such as hydroxychloroquine may be protective

Common symptoms of lupus

achy or painful joints and muscles

unexplained fatigue

fever without a known cause

rashes, especially across the cheeks and bridge of nose (usually caused by sun exposure)

frequent mouth sores ("singaw")

excessive hair loss and even balding

paleness

swelling of area around the eyes and the legs

fingers that turn white/blue with cold exposure

shortness of breath.

Flares

Period of SLE symptoms

periods when symptoms of the disease worsen or become more disruptive

can be mild and go away on their own, or they can be life-threatening and require medical treatment

Other symptoms

sun sensitivity

oral ulcers

arthritis

lung problems

heart problems

kidney problems

seizures

psychosis

blood cell and immunological abnormalities

Mild lupus

Joint and skin problems

Tiredness

Moderate

inflammation of other parts of the skin and body

including lungs, heart, kidneys

Severe

inflammation causing severe damage to the heart, lungs, brain, or kidneys

life threatening

Lab tests (CEK UA)

blood and urine tests

complete blood count

Erythrocyte sedimentation rate

Kidney and liver assessment

Urinalysis

Antinuclear antibody (ANA) test

Complete blood count

Measures the number of red blood cells, white blood cells and platelets as well as the amount of hemoglobin, a protein in red blood cells

Results may indicate you have anemia, which commonly occurs in lupus

 A low white blood cell or platelet count may occur in lupus as well

Erythrocyte sedimentation rate

determines the rate at which red blood cells settle to the bottom of a tube in an hour

A faster than normal rate may indicate a systemic disease, such as lupus

sedimentation rate isn't specific for any one disease

It may be elevated if you have lupus, an infection, another inflammatory condition or cancer

Kidney and liver assessment

can assess how well your kidneys and liver are functioning;

lupus can affect these organs

Urinalysis

may show an increased protein level or red blood cells in the urine; means lupus has affected kidneys

Antinuclear antibody (ANA) test

positive test for the presence of these antibodies — produced by your immune system — indicates a stimulated immune system.

most people with lupus have a positive ANA test, most people with a positive ANA do not have lupus.

If you test positive for ANA, your doctor may advise more-specific antibody testing

Nursing Responsibilities for Urinalysis

Instruct the patient to void directly into a clean, dry container.

• Sterile, disposable containers are recommended.

• Women should always have a clean-catch specimen if a microscopic examination is ordered

Collect specimens for infants and young children into a disposable collection apparatus consisting of a plastic bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis to permit voiding directly to the bag.

Cover all specimens tightly, label properly and send immediately to the laboratory.

Observe standard precautions when handling urine specimens

If your doctor suspects that lupus is affecting your lungs or heart, he or she may suggest

Chest X-ray

Biopsy

Chest X-ray

image of your chest may reveal abnormal shadows that suggest fluid or inflammation in your lungs

uses sound waves to produce real-time images of your beating heart. It can check for problems with your valves and other portions of your heart

Biopsy

Lupus can harm your kidneys in many different ways, and treatments can vary, depending on the type of damage that occurs

• It is necessary to test a small sample of kidney tissue to determine what the best treatment might be.

The sample can be obtained with a needle or through a small incision.

Skin biopsy is sometimes performed to confirm a diagnosis of lupus affecting the skin

immunoregulatory disturbance

exaggerated production of autoantibodies

immunoregulatory disturbance is brought about by some combination of (G HEM AB)

genetic factors

hormonal factors (as evidenced by the usual onset during the childbearing years)

environmental factors (eg, sunlight, thermal burns)

medications

antiseizure medications

B cells and T cells

B Cells

instrumental in promoting the onset and flares of the disease

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Corticosteroids (prednisone)

Intraarticular Injections (corticosteroids)

Systemic (corticosteroids)

Antimalarial drugs

BLyS-specific inhibitors

Immunosuppressive agents/chemotherapy

anticoagulants

Salicylates

Nonsteroidal anti-inflammatory drugs (NSAIDs)

OTC NSAIDs

• Ibuprofen

• Naproxen

• Celecoxib

Help reduce mild pain and swelling in joints and muscles

Administer drug with food, milk or antacids as prescribed or full glass of water

Report signs of bleeding; tarry stools, bruising, petechiae, nosebleeds, edema, skin rashes, persistent headaches, visual disturbances

Monitor BP for elevations related to fluid retention

Needs to be used regularly for maximal effect

Corticosteroids (prednisone)

Reduce swelling, tenderness, and pain

In high doses, they can calm the immune system

sometimes just called “steroids,” come in different forms:

• pills

• shot

• cream to apply to the skin

Lupus symptoms usually respond very quickly to these powerful drugs

• your doctor will lower your dose slowly until you no longer need it

The longer a person uses these drugs, the harder it becomes to lower the dose.

Stopping this medicine suddenly can harm your body.

Intraarticular Injections (corticosteroids)

Methylprednisone acetate (Depo-Medrol)

Triamcinolone (Aristospan)

• Anti inflammatory

• Analgesic

• Inhibits synthesis or release of inflammatory mediators

Use strict aseptic technique for joint fluid aspiration or corticosteroid injection

Inform patient that joint may feel worse immediately after injection

Inform patient that improvement lasts weeks to months after injection.

Advise patient to avoid overusing affected joint immediately after injection

Systemic (corticosteroids)

Hydrocortisone (Solu-cortef)

Methylprednisolone (Solu-Medrol)

• Anti inflammatory

• Analgesic

• Inhibits synthesis or release of inflammatory mediators

Used only in life-threatening exacerbations or when symptoms persist after treatment with less potent anti inflammatory drugs

Administer for limited time only, tapering dose slowly

Be aware that exacerbation of symptoms occurs with abrupt withdrawal of drug

Monitor BP, weight, CBC, potassium level

Limit sodium intake

Report signs of infection

Antimalarial drugs

Medicines that prevent or treat malaria also treat joint pain, skin rashes, fatigue, and lung inflammation.

Two common antimalarial medicines are:

• hydroxychloroquine (Plaquenil)

• chloroquine phosphate (Aralen)

taking antimalarial medicine can stop lupus flares and may help people with lupus live longer

Monitor CBC and hepatic function

Advice patient that therapeutic response may not occur for up to 6 months

Advise patient to immediately report visual difficulties, muscular weakness and decreased hearing or tinnitus

BLyS-specific inhibitors

limit the amount of abnormal B cells (cells in the immune system that create antibodies) found in people with lupus

Belimumab

common type of BLyS-specific inhibitor that treats lupus symptoms

blocks the action of a specific protein in the body that is important in immune response

Immunosuppressive agents/chemotherapy

used in severe cases of lupus

when lupus affects major organs and other treatments do not work

can cause serious side effects because they lower the body’s ability to fight off infections

• Evaluate for relief of pain, swelling, stiffness and increase in joint mobility

• Advise patient to immediately report unusual bleeding or bruising

• Advise patient that therapeutic response may take up to 12 weeks

• Advise women of childbearing age to avoid pregnancy

• Encourage increased fluid intake to decrease risk of hemorrhagic cystitis

• Monitor blood count and liver function tests ever 2-4 weeks for first 3 months of treatment; thereafter every 1-3 months

• Inform patient of increased infection risk

• Instruct patients not to take antacids at the same time

  • They may interfere with absorption of immunosuppressant

anticoagulants (“blood thinners”)

Warfarin

Heparin

to prevent your blood from clotting too easily

Many people with lupus are also at risk for blood clots, which can cause a stroke or heart attack

You cannot take ______ during pregnancy

warfarin

Salicylates

Aspirin

Anti-inflammatory, Analgesic, antipyretic, inhibits synthesis of prostaglandins

Administer drug with food, milk or antacids as prescribed or full glass of water

May use enteric-coated aspirin

Report signs of bleeding; tarry stools, bruising, petechiae, nosebleeds

Nursing Interventions relating to acute and chronic pain

Provide variety of comfort measures

• Application of heat or cold

• Massage, position changes, rest

• Foam mattress, supportive pillow, splints

• Relaxation techniques, diversional activities

Administer anti-inflammatory, analgesic, slow acting antirheumatic medications as prescribed

Individualize medication schedule to meet patient’s need for pain management

Encourage verbalization of feelings about pain and chronicity of disease

Teach pathophysiology of pain and rheumatic disease and assist patient to recognize that pain often leads to unproven treatment methods

Assist in identification of pain that leads to use of unproven methods of treatment

Assess for subjective changes in pain

Nursing Interventions related to Fatigue

Provide instruction about fatigue

• Describe relationship of disease activity to fatigue

• Describe comfort measures while providing them

• Develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep)

• Explain importance of rest for relieving systematic, articular and emotional stress

• Explain how to use energy conservation techniques (pacing, delegating, setting priorities)

• Identify physical and emotional factors that can cause fatigue

Facilitate development of appropriate activity/rest schedule

Encourage adherence to the treatment program

Refer to and encourage a conditioning program

Encourage adequate nutrition

• Include source of iron from food and supplements

Discharge planning

• Know the disease progress

• Names of drugs, actions, side effects, dosage, administration

• Pain management strategies

• Energy conservation and pacing techniques

• Therapeutic exercise, use of heat therapy (for arthralgia)

• Avoidance of physical and emotional stress

• Avoidance of exposure to individuals with infection

• Avoidance of drying soaps, powders, household chemicals

• Use of sunscreen protection (SPF 15) and protective clothing

• Minimal sun exposure from 11 AM to 3 PM

• Regular medical and laboratory follow-up

• Marital and pregnancy counseling as needed

• Community resources and health care agencies