A. Pusey Murray (Mrs)RN, Cert Psych Nursing & Nursing Admin, BSc (Hons), MPH, PgD. Education, PhD (c)

Systemic Lupus Erythematosus

Objectives At the end of this session students will be able to:Define the term Systemic Lupus Erythematosus.State the etiology of Systemic Lupus Erythematosus.Outline the pathophysiology of Systemic Lupus Erythematosus.

Objectives contd List at least ten (10) clinical manifestations of Systemic Lupus Erythematosus.Describe the nursing management of Systemic Lupus Erythematosus.

Definition Systemic Lupus Erythematosus is a chronic multisystem inflammatory disease of connective tissue that often involves the skin, joints, serous membranes (pleura, pericardium), kidneys, hematologic system and central nervous system.

Etiology The etiology of SLE is unknown. However factors implicated in the etiology of SLE includes genetic predisposition, sex hormones, race, environmental factors (ultra violet radiation, drugs, chemicals), viruses, infections and stress.

Pathophysiology Pathophysiology depends on auto immune reactions directed against constituents of the cell nucleus, particularly DNA. In SLE, auto antibodies are produced against nuclear antigens, cytoplasmic antigens and blood cell surface antigens, platelets and granulocytes. When auto antibodies bind to their specific antigens, complement activation occurs.

Pathophysiology contd Accumulation of immune complexes within the blood vessel walls and subsequent complement activation leads to a condition called lupus vasculitis. The ensuing ischemia within the blood vessel walls gradually leads to the thickening of the internal cell lining, fibrinoid degeneration and thrombus formation.

Pathophysiology contdThe specific manifestation of SLE depends on which cell types or organs are involved.SLE may be precipitated or aggravated by certain drugs such as procainamide and a number of anticonvulsant agents. Some antiinfective agents such as penicillin, sulfonamide and oral contraceptives may also aggravate the disease.

Clinical ManifestationsFatigueFever (>100 F)Skin rashesFacial rashAlopecia (hair loss)SeizuresArthritis

Clinical ManifestationsMouth or nose ulcersFatigue Butterfly rash on cheeks and bridge of nose

Blotchy Erythema of Dorsum of the Hands

Butterfly Rash

Malar Rash Butterfly rash

Oral Ulcer

Alopecia

Nursing ManagementImpaired skin integrity related to photosensitivity evidenced by areas of ulceration on finger tips, alopecia, butterfly rash on face.Altered nutrition less than body requirements related to oral ulcerations, immunosuppresive therapy evidenced by weight loss.

Nursing Management ContdAssess and monitor location and progression of rash.Administer prescribed medications and apply ointments as ordered to control skin manifestations.Keep skin dry and clean to prevent secondary infections.

Nursing Management ContdEncourage discussion about feelings and positive attributes to reduce clients sense of isolation and poor body image and redirect self-focus to positive attributes.Encourage client to rest regularly and as needed to temporarily reverse effect of fatigue.Provide range of motion exercises to unaffected joints to prevent contractures.

Nursing Management ContdProvide good oral hygiene before and after meals to provide comfort and prevent exacerbating oral ulcerations.Encourage patient to assist in setting activity schedule to allow patient a sense of control and foster cooperation.Monitor pertinent laboratory values such as hemoglobin, electrolytes and protein levels.

Nursing Management ContdNursing interventions should be directed towards assisting the patient and family to eliminate or minimize exposure to precipitating factors. Patient understanding and cooperation are important to this goal. Patient and family education should include the following:

Nursing Management ContdAn abnormal reaction to the ultraviolet (UV) rays of the sun, photosensitivity results in the development or exacerbation of a rash that is sometimes accompanied by systemic symptoms. All people with lupus should avoid direct, prolonged exposure to the sun. Sun-sensitive patients should frequently apply a sunscreen.

Nursing Management Contd Sun-sensitive patients should also avoid unprotected exposure between 10 a.m. and 4 p.m., and wear protective clothing, such as wide-brimmed hats and long sleeves. In severe cases, patients may wish to purchase special UV-blocking clothing.

Nursing Management ContdEducation on the disease process.Names of medications, and actions, side effects, dosage and administration.Avoidance of physical and emotional stress, over exposure to ultra violet light and unnecessary exposure to infections.Regular medical and laboratory follow up.

Nursing Management ContdTeach your patient and her family to watch for signs of exacerbation: fever, rash, cough, or worsening muscle and joint pain. Decreased urine output or unexplained weight gain may signal renal problems.

Nursing Management Contd Teach client about medications and discuss the common adverse effects. For example, taking cortico-steroids with a meal will help her avoid gastrointestinal irritation. To promote adequate nutrition, teach your patient to eat small, frequent meals. Good oral hygiene may help prevent the development of oral ulcers.

Nursing Management contdTo prevent joint pain and deterioration, teach her joint conservation measures. For example, when arising from a chair, she should push with her arms to decrease the strain on her hips and knees.

Nursing Management contdMedications (such as aspirin or NSAIDs), warm and cold compresses, and relaxation techniques all may help control pain.Referral resources to community and health care agencies.

Critical Thinking QuestionWhat are the lifestyle implications of being diagnosed with Systemic Lupus Erythematosus?

References Beers. M. (2004). The Merrick Manual of Medical Information (2nd ed.).

Greener, M.(1991)."SLE: A Clinical Challenge," Professional Nurse. 6(10), 589-592

White, L., Duncan, G., & Baumle, W. (2013). Medical Surgical Nursing. An Integrated Approach.(3rd ed.), Delmar, Cengage Learning.USA.

References Williams & Wilkins (2006). Handbook of Medical Surgical Nursing (4th ed.). Lippincott