Systemic Lupus Erythematosus (SLE) & Human Immunodeficiency Virus (HIV)

Systemic Lupus Erythematosus (SLE)

• Two Main Classifications of Lupus:

  • Discoid lupus erythematosus: Affects only the skin.

  • Systemic lupus erythematosus (SLE): Affects major body organs and systems.

Expectations for this session:

• Potential etiology and assessment findings of SLE.

• Laboratory tests for diagnosing SLE.

• Nursing considerations for caring for a client with SLE.

Case Study: Ellis

• Ellis, a 34-year-old female in Southern Arizona.

• Symptoms:

  • Increased tiredness.

  • Pain in ankles and hips.

  • Multiple reddened areas on skin.

• Married for ten years with two children (ages 4 and 10).

• Recent miscarriage, light to no menses in the past six months.

• Family History:

  • Father passed away from leukemia.

  • Sister has ulcerative colitis.

• Increased workload, feeling stressed and missing kids' activities.

• Antibody panel and urinalysis ordered by healthcare provider who suspects SLE.

• Referred to a hematologist.

Questions:

1. What signs and symptoms lead the healthcare provider to suspect SLE?

2. What recent changes in Ellis's life could contribute to an SLE diagnosis?

Answers:

1. Signs and Symptoms:

   • Increased tiredness leading to fatigue.

   • Joint pain.

   • Skin changes (rashes/lesions).

   • Exposure to UV light (lives in Southern Arizona).

2. Recent Changes:

   • Recent miscarriage and hormonal imbalance (light/missed menses).

   • Increased workload and stress (missing kids' activities).

IMPACT Style Case Study Question:

A client diagnosed with Systemic Lupus Erythematosus is admitted to hospital with deep vein thrombosis. Which client statement requires an intervention by the nurse?

1. I feel better today, but I'm still experiencing some minor joint pain.

2. I need to avoid contact with my son because he is sick with the flu.

3. Light walking and tai chi help me cope with my symptoms.

4. After this hospital stay, I'm looking forward to not having to deal with any more symptoms again.

• The credited answer is number 4.

• SLE is a lifelong disease that requires medical and symptom management.

• It is often characterized by exacerbations or flare-ups where symptoms can worsen or new symptoms present.

SLE: What We Know and Don't Know

• What we know:

  • Autoimmune disease.

  • Abnormal immune response related to:

    • Genetic causes.

    • Environmental causes.

    • Hormonal causes.

• What we don't know:

  • The exact cause.

Medications that can trigger SLE:

• >40 medications that can trigger SLE.

• Top 3:

  • Hydralazine.

  • Procainamide.

  • Quinidine.

Risk Factors:

• Gender: Women are more likely to develop SLE than men.

• Age: Women of childbearing age (15-44 years) are at the greatest risk.

• Race and ethnicity: African Americans, Hispanics/Latinos, Asian Americans, Native Americans, Native Hawaiians, and Pacific Islanders are more likely to develop SLE than Caucasians.

Understanding the Terminology:

• Systemic: Body-wide.

• Lupus: Latin word for wolf; refers to skin lesions on the face.

• Erythematosus: Red.

• Reddened area on cheeks and nose resembles a wolf.

Assessment Findings:

• Dermatology Findings:

  • Vascular lesions.

  • Butterfly rash (malar rash) on the cheeks and nose.

  • Round, point-shaped lesions.

  • Lesions in the mouth and nose (nasopharyngeal lesions).

  • Alopecia.

• Kidneys:

  • The number one internal organ affected (75% of clients).

• Joints:

  • Joint pain (arthralgia) is very common.

• Lungs and Heart:

  • Fibrosis of sinoatrial and atrioventricular nodes leading to dysrhythmias.

• Nervous System:

  • Both physical and psychosocial issues and symptoms.

• Blood Disorders:

  • Occur more frequently in clients with SLE.

• Infection:

  • Increased risk for infection due to impaired phagocyte function and decreased antibody production (immunosuppressive effect).

  • Pneumonia is a major cause of death.

  • Vaccines are generally safe, but virus vaccines should be avoided if the client is being treated with corticosteroids or cytotoxic medications.

Diagnosis of SLE

• Combination of symptoms and lab testing.

Lab Testing:

• Antibodies (antinuclear antibodies or ANA).

Assessment Criteria:

• Malar rash (butterfly rash).

• Discoid rash (round, coin-like, raised patches with scaling and follicular plugging).

• Nonerosive arthritis (arthralgia).

• Pleuritis or pericarditis.

• Renal dysfunction.

• Neurological dysfunction.

• Hematologic dysfunction.

• Immunologic.

• Abnormal ANA titer.

• Four or more criteria must be present for diagnosis of SLE.

Nursing Considerations

• Managing Symptoms:

  • SLE is manageable but not curable.

• Laboratory monitoring:

  • Urinalysis (renal involvement).

  • CBC (hematologic involvement).

  • ESR and CRP (disease activity and therapy effectiveness).

  • Serum electrolyte levels, cardiac enzymes, liver enzymes, clotting factors (body system functioning).

• Focus on patient's ability to move and function (ADLs).

Neurological Issues:

• Vision changes.

• Peripheral neuropathies.

• Seizures and memory loss.

• Psychosocial signs (personality changes, increased pain, difficulty dealing with condition).

Treatment

• There are periods of stability and flare-ups.

• Reduce incidence of flare-ups.

• Manage the disease process and maintain optimal health.

Proactive Pain Management:

• Acetaminophen (joint and muscle pain).

• NSAIDs (joint and muscle pain and inflammation, if renal function is normal).

• Corticosteroids (oral prednisone or topical cortisone).

• Cyclophosphamide (cytotoxic agent).

• Hydroxychloroquine (antimalarial agent to decrease UV light absorption by the skin).

• Methotrexate or azathioprine (immunosuppressive agents).

• Belimumab (biological medication).

Additional Recommendations:

• Therapeutic exercise.

• Energy conservation to decrease fatigue.

• Marital and pregnancy counseling.

• Routine visits to the healthcare provider for lab work monitoring and medication management.

Reactive: Things to Avoid

• Physical and emotional stress.

• Prolonged exposure to the sun or UV light.

• Drying soaps, detergents, or chemicals.

• Harsh or perfumed substances.

• Exposure to infection or infectious diseases.

Case Study: LS Revisited

• LS visits a hematologist who confirms SLE diagnosis.

• Recommendations:

  • Initial round of steroids followed by prescription for adalimumab.

  • Reduce stress.

  • Examination by a nephrologist and an endocrinologist.

  • Home health nurse visits for education on SLE and lifestyle changes.

Questions for the Home Health Nurse:

1. What lifestyle factors would you address with LS?

2. What nursing teaching do you anticipate for LS concerning her stress level?

Answers:

1. Lifestyle Factors:

   • Possibility of having more children and contraception methods.

   • Maintaining adequate energy to cope with the disease.

   • Pain management.

   • Avoiding prolonged exposure to UV light.

   • Evaluating workload.

   • Developing effective stress coping techniques (meditation, light exercise, breathing exercises, spiritual development).

2. Stress-Coping Techniques:

   • Gentle, not strenuous, exercise.

In-Class Style Question:

The nurse discusses the plan of care for a client diagnosed with systemic lupus erythematosus. The nurse will intervene if which goal is included in the client's plan of care? Select all that apply.

1. Restriction of heat therapy to help relax sore muscles and joints.

2. Lessen strenuous exercise to improve energy.

3. Avoiding all sun and ultraviolet light exposure.

• The credited answers truly are one, two, and three.

Human Immunodeficiency Virus (HIV)

Learning Objectives:

• Identify the transmission and prevention of HIV.

• Review the clinical manifestations and diagnosis of HIV.

• Explore nursing and medical management of a client diagnosed with HIV.

Case Study: Mr. Johnson

• Mr. Johnson, a 55-year-old bisexual African American male.

• Symptoms: New onset of fever, fatigue, and a sore throat.

• Rapid strep and nasal swab for flu are negative.

• Reports unprotected sexual encounters with multiple male partners of unknown HIV status over the past several months.

Questions:

1. What in Mr. Johnson's health history concerns you?

2. What could be the cause of Mr. Johnson's symptoms?

3. Is he a candidate for post-exposure prophylaxis medications?

Answers:

1. Concerns:

• Bisexual male in the highest risk category for HIV.

• New onset of fever, fatigue, and sore throat (flu-like symptoms).

• Unprotected sex with multiple partners increases his risk.

1. Cause of Symptoms:

• Could indicate HIV.

• Consistent with an acute HIV infection (usually occurs two to four weeks after initial infection).

1. Candidate for PEP:

• No. It is too late; past the 72-hour window for PEP effectiveness.

NCLEX Style Question:

The nurse provides care for a client in an outpatient clinic. The nurse determines which client is at greatest risk for contracting HIV.

• Answer choice number two (A young adult homosexual male having unprotected sex with multiple partners) has two risk factors.

• Answer choice number two is the credited answer.

Risk Factors for HIV:

• Being a homosexual male.

• Having unprotected sex with multiple partners.

Transmission of HIV

• HIV is transmitted through certain body fluids:

  • Blood.

  • Semen.

  • Vaginal secretions.

  • Breast milk.

• Risk of transmission through oral sex is extremely low, but possible.

• Sharing needles or equipment used for injection with someone who is HIV positive.

  • HIV can live on these needles for up to 42 days.

• From infected mother to baby during pregnancy, delivery, or breastfeeding.

  • If a baby is born to an untreated mother with HIV, they have a 25% chance of being born with the disease.

Where HIV is NOT Transmitted:

• Air, tears, saliva, urine, emesis, sputum, sweat, or feces.

• Cannot be spread through social kissing, drinking from the same cup, hugging, touching the same surfaces as the infected individual, sharing a toilet, or coughing.

How to Prevent the Transmission of HIV:

• Reducing the risk of behaviors that cause exposure to the bodily fluids that carry the HIV virus.

• Reducing high-risk sexual behaviors.

• Limiting the number of sexual partners and condom use.

• Choosing less risky sexual behaviors.

• Remember that anal sex is higher risk than vaginal sex, which are both more risky than oral sex.

• Injection drug users should never share needles, syringes, or any other equipment that may have exposure to blood.

Using Medication to Prevent and Treat HIV

• HIV prophylaxis may be used in some high-risk groups to prevent the transmission of the disease.

• Use of pre-exposure prophylaxis (PrEP) to prevent HIV transmission.

• Clients that are having sex with someone who has tested positive for HIV.

• Clients that are having unprotected sex with members of high risk groups.

• Clients that are sharing needles for injection drug use.

• Post-exposure prophylaxis (PEPCan be used to prevent transmission of HIV to clients after they have known or suspected exposure to HIV.

• Post-exposure prophylaxis should be started as soon as possible after exposure, within 72 hours.

Diagnosis of HIV

• Diagnosis is made based on detection of HIV-specific antibodies.

  • Enzyme immunoassay (EIA), also called ELISA (enzyme-linked amino absorbent assay).

  • Western blot.

  • Immunofluorescence assay.

HIV Infects and Destroys CD4 T Cells

• Monitor CD4 count and viral load.

• A normal CD4 T cell count ranges from 800 to 1,200 cells per microliter.

• As the disease progresses, the CD4 count will decrease.

• Viral load is a measure of the HIV virus in a sample of blood and provides information on disease progression.

• During initial infection, that viral load will be high, and then it will drop.

• When the disease progresses to AIDS or acquired immunodeficiency syndrome, the viral load will increase once again.

Clinical Manifestations

Acute Infection

• Usually lasts 1-2 weeks.

• Individuals will experience flu-like symptoms of acute infection.

• Viral load will be very high and CD4 will decrease temporarily.

Asymptomatic HIV

• Asymptomatic years of HIV disease.

• CD4 count remains above 500 cells per microliter.

• No disease symptoms, though the client is still contagious.

Symptomatic Infection

• The disease progresses to where the CD4 count will go below 200-500 cells per microliter and the viral load will increase.

• HIV disease becomes symptomatic at this stage of the disease.

• Clients may develop chronic fevers, frequent night sweats, chronic diarrhea, and fatigue during this stage.

• Contraction of opportunist infections also are likely to occur during this stage.

AIDS

• CD4 count drops below 200 cells per microliter.

• Leads to opportunist infections, opportunist cancers, and or wasting syndrome.

• These clients are in the final stage of HIV called AIDS.

• Symptoms of wasting symptoms in HIV include unintentional weight loss, fatigue, and decreased lean body mass.

Nursing and Medical Management for HIV

• Aim is to slow disease progression with antiretroviral drugs.

• Goals of treatment: a decrease in viral load, an increase in the CD4 T cell count and prevention of opportunistic infections.

• Reinforcing adherence to treatment: Educating that the risk of drug resistance is high, encouraging clients to take their meds precisely as prescribed and to talk to health care providers if they cannot tolerate.

Infection Prevention

• Key action: Taking medications for HIV exactly as prescribed.

• Essential vaccines: hepatitis B human papillomavirus, the T gap, influenza, meningococcal, and pneumococcal vaccinations.

Food preparation:

• Avoid undercooked meats and eggs, urized milk and unclean drinking water sources.

Pet Exposure:

• Wash hands after handling a pet and should be careful to wear gloves if they may come in contact with animal feces.

Human contact:

• Wash hands frequently, avoiding large crowds, and avoiding exposure to sick individuals.

Home Cleaning:

• Wash hands carefully and clean the surfaces. They need to keep the client separate to those that may have an infectious disease.

Opportunistic Infections

• Pneumocystic uroveci pneumonia.

• Candidiasis.

• Cytomegalovirus.

• Mycobacterium avium complex.

• Tuberculosis.

• Kaposi sarcoma.

Nursing Actions for Wasting Syndrome.

*Monitor weight and hydration and encourage a high calorie/ protein diet.

Psychosocial Support. Social isolation, depression, it can lead to feelings of powerlessness.

Evaluate, Help, Educate.

Case Studies

Case Study Mr. Francis 43-year-old male

• What concerns do we have for Mr. Francis?

• What could be the cause of those skin lesions?

• What nursing care can you provide for mister Francis?

NCLEX Style Question:

The nurse provides care for a client diagnosed with HIV. The nurse knows to follow-up on which client statement.

Follow up on answer choice 4

I know my medications are working if my viral load is high and my CD four T cell count is low.