WEEK 10: Chapter 64 Arthritis and Connective Tissue Diseases Systemic Lupus Erythematosus

clinical manifestations of SLE

1. Facial rash confined to the cheeks (malar rash) 2. Discoid rash (raised patches, scaling) 3. Photosensitivity (skin rash developed as a result of exposure to sunlight) 4. Oral or nasopharyngeal ulcers 5. Nonerosive arthritis of at least two peripheral joints 6. Serositis (pleurisy, pericarditis) 7. Renal disorder (proteinuria of 0.5 g/day or cellular casts) 8. Neurologic disorders (seizures or psychosis) 9. Hematologic disorders (hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia)

The diagnosis of SLE is established by the presence of distinct criteria obtained from patient history, physical examination, and laboratory findings such as

ANA **presence of ANA **97% of people with SLE have positive ANA DNA Antibodies *half of the people with SLE have anti-double-stranded DNA antibodies *anti-Smith antibodies found in 30-40% of individuals Other Antibodies Other antibodies present in SLE may include: Antineuronal Anticoagulant Anti-white blood cell (WBC) Anti-red blood cell (RBC) Antiplatelet Antiphospholipid Anti-basement membrane Antiphospholipid syndrome is associated with SLE and can cause pregnancy complications. Other Diagnostic tests Complete blood count (CBC) - may reveal leukocytosis. Serum complement level helps diagnose and monitor disease activity and treatment. Urinalysis reveals proteins or cellular casts in the urine. Lupus erythematosus cell prep test is a nonspecific test for SLE; the result is also positive in patients with other rheumatic diseases. Elevated erythrocyte sedimentation rate and C-reactive protein levels are not diagnostic of SLE but may be used in monitoring. X-rays of joints and chest show effects on the musculoskeletal system and lungs. Electrocardiogram determines the cardiac effects of the disease.

Question 2 of 3 A female patient presents to the primary care clinic with a reddened, raised rash over her nose and cheeks. The patient also complains about painful joints in her left hand. Which laboratory tests would the nurse anticipate being ordered by the provider to confirm a diagnosis of systemic lupus erythematosus (SLE)?

Anti-DNA antibody test Anti-DNA antibody test results are positive in half of the patients with a confirmed diagnosis of SLE. Thus this laboratory test would be ordered for a patient with a butterfly rash. Antiphospholipid antibody test Antiphospholipid antibodies are found in patients with SLE. Therefore this laboratory test would be ordered for a patient with a characteristic butterfly rash on the face. Antinuclear antibody (ANA) test An ANA test is performed when a patient presents with symptoms of SLE. About 97% of patients with SLE have a positive ANA test result.

Question 8 of 9 A nurse is caring for a patient diagnosed with systemic lupus erythematosus (SLE) who has been on a long-term regimen of methylprednisolone. Which precautions should the nurse take to prevent complications of the treatment?

Assess the patient's mental status- The patient is taking methylprednisolone, which can cause psychosis in high doses. Therefore the nurse should carefully monitor the patient's mental status and report any changes, such as confusion, to the health care provider. Monitor the patient's blood glucose levels- A patient taking methylprednisolone can have a long-term complication of hyperglycemia, so the nurse should carefully monitor this patient's blood glucose levels.

Question 3 of 3 A patient with suspected systemic lupus erythematosus (SLE) asks the nurse which symptoms of the disease are likely to occur. Which manifestations should the nurse include?

Blood in the urine Hematuria is common in patients with SLE because the disease affects the kidneys and allows blood to spill into the urine. Facial butterfly rash A butterfly rash is the most common manifestation of SLE and appears over the nose and cheeks.

Question 5 of 9 A nurse is caring for a patient with systemic lupus erythematosus (SLE) who reports having mild pain and swelling in the hands. Which medication would the nurse anticipate the health care provider to prescribe?

Celecoxib Celecoxib is a nonsteroidal anti-inflammatory drug that is prescribed to treat arthritic pain related to SLE.

Question 3 of 3 The nurse is caring for a newly admitted patient with an exacerbation of systemic lupus erythematosus (SLE). Which interventions should the nurse perform?

Collect frequent urine samples The nurse should collect urine samples regularly so the urine can be tested for proteinuria and casts to monitor disease progression. Check patient for signs of hemorrhage The nurse should monitor the patient for signs of bleeding. Monitor the patient's intake and output The nurse should monitor the patient's intake and output because SLE can cause kidney damage.

Pathophysiology of SLE

In SLE, the individual's body makes various antibodies against the DNA proteins, erythrocytes, coagulation factors, lymphocytes, platelets, and other proteins. >>>Antinuclear antibodies (ANAs) attack the proteins of the DNA strand >>>Immune complexes (antigen-antibody complexes) lodge inside the basement membranes of the skin, kidneys, heart, brain, and joints. >>>These immune complexes initiate an inflammatory response that destroys tissue in the area. >>>B cells and T cells trigger an exaggerated immune response as well. This causes further tissue destruction.

Question 1 of 3 A patient is undergoing diagnostic testing for suspected systemic lupus erythematosus (SLE). Which assessment findings may help confirm the diagnosis?

Malar rash A patient is diagnosed with SLE when he or she has four or more symptoms. One of the symptoms is a malar rash on the face. Photosensitivity At least four specific SLE-related symptoms are required for a diagnosis of SLE. One of the symptoms is sensitivity to natural or artificial light. Multiple swollen and painful joints Pain in two or more joints is one of the four diagnostic criteria for SLE.

Question 3 of 3 A patient with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti-inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

Melena A patient receiving NSAIDs may have gastrointestinal bleeding. The signs and symptoms of this are dark, almost black stools (melena). If the nurse suspects that blood is present in the stool, he or she should notify the health care provider and expect an order for guaiac testing of the stool.

Etiology of Systemic Lupus Erythematosus

Not known; genetic, hormonal factors, **after menarche **with the use of oral contraceptives **during and after pregnancy **immediate postpartum period when the condition worsens Environmental factors: >>stress, >>>overexposure to UV light, >>chemical/toxin exposure >>viral infections MEDICATIONS: *procainamide *Hydralazine *Quinidine *Associates with at least 40 other prescription drugs

Diagnostic Criteria for SLE

Patient has SLE if they have 4+ of the following are present at any time: 1. Mucocutaneous signs (each counts as one): butterfly rash, photosensitivity, oral or nasopharyngeal ulcers, discoid rash ( raised rash that causes follicular plugging and scarring) **photosensitivity (rash formed after exp. to light) **oral ulcers ( painless ulcers in oral cavity) 2. Arthritis (Two or more peripheral joints that are tender, swollen, and warm) 3. Pericarditis, pleuritic 4. Hematologic disease: hemolytic anemia w/ reticulocytotic, leukopenia, lymphopenia, thrombocytopenia 5. Renal disease: proteinuria >0.5 g/day, cellular casts 6. CNS-- seizures, psychosis 7. Immunologic manifestations: positive LE prep, false + test for syphilis 8. ANAs (positive titers)

Question 2 of 3 Which plasma proteins and blood cells are affected by the autoimmune response in systemic lupus erythematosus (SLE)?

Platelets Platelets are cells that help with blood clotting. They are affected by the autoimmune response in SLE. Lymphocytes Lymphocytes are white blood cells that are affected by the autoimmune response in the disease process of SLE. Clotting factors Clotting factors are plasma proteins that are affected by the autoimmune response in SLE.

Question 3 of 9 Which finding in a patient with systemic lupus erythematosus (SLE) would indicate possible kidney damage

Protein in the urine Proteinuria is a common finding in patients with SLE and indicates possible kidney damage.

Nursing Goals for the Patient with SLE

These include: Reporting satisfactory pain management Complying with the treatment regimen Verbalizing an understanding of activities to avoid and ways to prevent complications Maintaining independence Demonstrating a positive self-image

Question 1 of 3 Which factor could trigger an exacerbation of systemic lupus erythematosus (SLE)?

Ultraviolet (UV) light exposure Patients with SLE are photosensitive, and their exposure to light, including the sun and UV light, can exacerbate the disease. A butterfly rash over the nose and cheeks would develop after exposure.

Question 6 of 9 A female patient comes to the emergency department with a butterfly rash and tests positive for antinuclear antibodies. Which additional tests would the nurse anticipate to be ordered by the health care provider to confirm a diagnosis of systemic lupus erythematosus (SLE)?

Urinalysis- Urinalysis can confirm whether there is a protein or any other indicator of kidney disease in the urine, which is a positive indicator of SLE. Serum complement test-A serum complement test will confirm serositis, which is a positive indicator of SLE.

Question 1 of 9 The nurse is caring for a patient with a new diagnosis of systemic lupus erythematosus (SLE). The patient denies a family history of this disease. Which information in the patient's history identifies a likely cause of the onset of symptoms?

Use of prescribed procainamide At least 40 prescription medications, including procainamide, can lead to the development of SLE.

SLE is a

chronic autoimmune disease that causes an individual's immune system to attack healthy tissue

SLE can affect almost any organ and produces various effects in thE

integumentary, urinary, cardiopulmonary, gastrointestinal, musculoskeletal, neurologic, and hematologic systems.

When assessing a patient with SLE, the nurse should obtain the

medical history, including family history, current, and past medication use, pain level, and remission/exacerbation history. A head-to-toe assessment would detect rashes, petechiae, murmurs, mental status, difficulty with ambulation, and Raynaud's phenomenon.

SLE is usually managed in an outpatient setting, but when the patient has an acute exacerbation, hospitalization may be necessary. Nursing interventions when a patient is hospitalized include

medication administration, assessing fluid and electrolyte balances and neurologic status, and checking for signs of bleeding/bruising.

For patients with SLE in the more advanced stages, discussions about:

quality of life and end-of-life care need to be initiated. When multiple organs become dysfunctional, end-of-life decisions need to be made. This is a difficult conversation to have, but it must be initiated before the patient's mental status is compromised. The nurse should act as patient advocate to ensure that this takes place.

The nurse is responsible for educating the patient about

safe medication use, ways to manage pain, avoiding sunlight and using sunscreen, relaxation techniques, and avoiding people who are sick.

Systemic lupus erythematosus (SLE)

the disease that causes the body's immune system to attack healthy tissue effects: joints, skin, serous membranes, and renal hematologic and neurologic systems ***butterfly rash on face*** >>effects mostly women 6 to 10 times more than men

Question 4 of 9 A patient diagnosed with systemic lupus erythematosus (SLE) is taking methotrexate. Which instruction should the nurse provide to the patient?

"You need to take a folic acid supplement." Methotrexate depletes folic acid. Therefore supplementation is required.

Question 2 of 9 A patient with systemic lupus erythematosus (SLE) asks the nurse what happens during an exacerbation of SLE. Which response from the nurse is appropriate?

"Your body is making antibodies that attack the proteins in your DNA." SLE is an autoimmune disease. An individual with SLE develops antibodies that attack the proteins found in his or her DNA.

medications for SLE

-corticosteroids: control inflammation Prednisone Methylprednisolone -antimalarial: controls skin lesions, renal and arthritic problems: Treatment of fatigue, skin, and joint problems related to SLE Hydroxy-chloroquine Chloroquine -NSAIDs: muscle/joint pain Ibuprofen Naproxen Aspirin Celecoxib -immunosuppressant: control SLE Methotrexate : Antineoplastic agent for cancer but used as immunosuppressant for management of SLE -vitamin D: bone support **Topical immunomodulators: Treatment of severe skin conditions; used instead of corticosteroids Tacrolimus Pimecrolimus

Question 9 of 9 A patient with systemic lupus erythematosus (SLE) mentions to the nurse that she is trying to conceive. Which questions should the nurse ask to address potential pregnancy complications?

"Are you currently taking methotrexate?" Methotrexate is a medication used to manage SLE symptoms that can cause birth defects or miscarriages. The patient should know about the side effects of methotrexate if she is trying to become pregnant and should speak to the health care provider about steps that can be taken. "Have you and your partner started pregnancy counseling?" The nurse should ask the patient about pregnancy counseling because counseling will help the patient identify potential complications that may affect pregnancy.

Question 1 of 3 Which instructions should the nurse include in the teaching plan when educating a patient and his or her caregiver about systemic lupus erythematosus (SLE)?

"Avoid excessive exercise in order to conserve your energy." Patients with SLE should work on methods to conserve energy, and the nurse should provide tips to help the patient with this.

Question 2 of 3 A patient with systemic lupus erythematosus (SLE) presents with a malar and discoid rash. As the nurse is assessing the patient, which question should the nurse ask?

"Have you spent time outside during the day lately?" The nurse should ask the patient if he or she has spent time outside during the day because exposure to ultraviolet light may have caused the rash.

Question 7 of 9 The nurse has established a goal of verbalizing an understanding of activities to prevent exacerbations with a female patient with systemic lupus erythematosus (SLE). Which statement made by the patient would support this goal?

"I plan to do meditation daily and take time for myself." The patient's statement that she plans to meditate and set aside time for herself every day indicates that she understands the impact of stress on the disease process.