Download Case Study #87: Systemic Lupus Erythematosus


https://www.youtube.com/watch?v=he
RWz1Qmu4Q

Listen to his words and accent

Chronic, autoimmune
disease that can affect
literally any body system

Rarely presents the same
in any two lupus patients

Disruption in apoptosis
 Immune system generates
auto-antibodies
› Antibodies clump together
and can latch on to any
body system. Attacking
cells DNA surrounding the
antibody.
No known cause
 No know treatment to
cure the disease

› Treatment is aimed at
reducing symptoms and
balancing the body’s
immune system to a
functional level
› Genetic, epigenetic,
hormonal, and other
environmental factors
associated with SLE
250,000 Americans
diagnosed with definite
SLE (NADWG).
 90% in women of
childbearing age
 Incidence of SLE in black
women 4x higher than
that in white women

D.W. Is a 25-year-old
married woman with three
children under 5 years old. She
came to her physician 7
months ago with vague
complaints of intermittent
fatigue, joint pain, low-grade
fever, and unintentional weight
loss.
Her physician noted small,
patchy areas of vitiligo and
scaly rash across her nose,
cheeks, back, and chest.

Positive antinuclear
antibody(ANA) titer

Positive dsDNA(positive lupus
erythematosus)

Positive anti-Sm(anti-smooth
muscle antibody)

Elevated C-reactive protein(CRP)

Elevated erythrocyte
sedimentation rate (ESR)

Decreased C3 and C4 serum
complement
Joint x-ray films demonstrated joint swelling without
joint erosion. D.W was subsequently diagnosed with
systemic lupus erythematosus (SLE).
She was initially treated with hydroxychloroquine
(Plaquenil) 400mg and Deltason (Prednisone) 20mg PO
qdaily, bed rest, and ice packs.
› D.W responded well to treatment, the steroid was
tapered and discontinued, and she was told she could
report for follow-up every 6months, unless her
symptoms became acute. D.W. Resumed her job in
environmental services at a large geriatric facility.

Positive antinuclear antibody (ANA) titer:
› Auto-antibodies are in the immune system

Positive dsDNA (positive lupus
erythematosus):
› Auto-antibodies that target DNA
› Highly specific

Positive anti-SM (smooth muscle
antibody):
› Presence of antibodies against smooth
muscle

Elevated C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR)
› Measure of inflammation in the body

Decreased C3 and C4 serum
complement
› Shows impending or current “flare” of lupus
symptoms

11 criteria for SLE
› Established by
the American
Rheumatism
Association
› If individual
display 4 or more
of these criteria,
SLE diagnosis is
highly suggested.

Known as a “butterfly” rash
› D.W. displays scaly rash over cheeks, nose,
back and chest.
Discoid skin rash
 Photosensitivity
 Two or more
swollen/tender joints

› Shown both subjectively
and objectively

Brain irritation
› Seizures or psychosis
(lupus cerebritis)
Mucous membrane ulcers
 Pleuritis or pericarditis

Low blood counts
 Kidney abnormalities

› Proteinuria

Tests:
› dsDNA, anti-Sm, ANA
› ESR and CRP
Coping and
understanding of dx
 Monitor pain and temp
 Medication
administration and
understanding
 Ways to live a normal
and safe life dx. w/ SLE

Eighteen months after
diagnosis, D.W. Seeks out
her physician because of
puffy hands and feet and
increased fatigue. D.W.
Reports that she has been
working longer hours
because of the absence of
two of her fellow workers.

Laboratory Test Results (8 months after
dx):
Sodium
129mmol/L
Norm =135-145
Potassium
4.2mmol/L
Norm=3.5-5.2
Chloride
119mmol/L
Norm=96-106
Total CO2
21mmol/L
Norm=20-29
BUN
34mg/dL
Norm=8-20
Creatinine
2.6mg/dL
Norm=0.6-1.1
Glucose
123mg/dL
<140
Urinalysis
2+ protein
1+ RBCs
Elevated BUN
and Creatinine
 Proteinuria and
hematuria
 Slightly
elevated
sodium and
chloride

Stabilize labs
 Decrease swelling and
fatigue
 Medication adjustment
 Promote kidney function
 Decrease risk of infection

6) The physician orders cyclophosphamide
(Cytoxan) 100mg/m2/day orally in two
divided doses. D.W. Weighs 140 lbs and is
5ft, 4in tall. How much will she receive
with each dose?

cyclophosphamide (Cytoxan)
› Aklylating agent used for immunosuppressant
therapy
› Used for D.W.’s worsening symptoms of SLE
D.W. Is seen in the immunology clinic twice monthly
during the next 3 months. Although her condition
does not worsen, her BUN and creatinine remain
elevated. While at work one afternoon, D.W. Beings
to feel dizzy and develops a severe headache. She
reports to her supervisor, who has her lie down.
When D.W. Starts to become disoriented, her
supervisor calls 911, and D.W. Is taken to the
hospital. D.W. Is admitted for probable lupus
cerebritis related to acute exacerbation of her
disease.
Seizures
 Decreased LOC
 Slurred speech
 PERRLA
 A&O
 Muscle tone
 Symmetry

Seizure
precautions
 Infection control

› Standard
precautions
› IV antibiotics
Close monitoring
 Neurological
assessments

9) While caring for D.W., which of these care activities
can be safely delegated to the NAP? (select all that
apply):
 a: Measuring D.W.'s BP every 2hrs
 b: Assisting D.W. With personal hygiene measures
 c: Counseling D.W. On seizure safety precautions
 d: Assessing D.W.'s neurological status every 2hrs
 e: Emptying the urine collection device and
measuring the output
 f: Monitoring D.W.'s BUN and creatinine levels

A,b,e
The physician orders
pulse therapy with
methylprednisolone (SoluMedrol) 125mg IV every 6
hours and plasmapheresis
once daily.
Increased risk of
infection
 Change in VS
 N/V, bone marrow
suppression, hair
loss, lethargy

Blood is taken out,
plasma is filtered out,
replaced with other
fluids, and replaced
back into the body.
 Plasma contains
inflammatory
antibodies and other
immunologically
active substances

12) D.W. Returns to the floor following
plasmapheresis. The NAP reports to you
D.W.'s vital signs.
BP=86/43, HR=108, RR=18, Temp=97.2(36.2)
You go in to assess D.W. And find that
she is complaining of a headache and
some dizziness.

BP=86/43, HR=108, RR=18, Temp=97.2(36.2)
› Hypotensive- from plasmapheresis
› Dehydrated
Stabilizing BP
 Hydrating
 Decrease dizziness and headache
 Stabilize temp
 Assessing neurological signs and VS

› Keeping doctor aware of any complications
Stable VS
 A&O x4
 Decreased report of
pain and swelling
extremities
 Decrease in fatigue
 Decrease in
inflammation
 Fight off infection

1)
2)
3)
4)
5)
Medication regimen
Coping
Proper hygiene
Self-care with SLE and
kidney complications
When to notify health
care provider
16) You note that D.W.'s husband is visiting her
this afternoon. You enter the room to as
whether they have any questions. D.W.'s
husband states, “I have tried to tell her that
she cannot go back to work. Sure, we need
the money, but the kids and I need her
more. I’m afraid that this lupus has
weakened her whole body and it will kill her
if she goes back to work. Is that right?” How
should you respond to his concerns?
Main cause of SLE
 Treatments aimed at curing
the disease rather than
managing it

› grasp further understanding
for health care workers to
take the best care possible
for SLE patients







Ramachandran, R. R., Sakhuja, V. V., Jha, V. V., Kohli, H. S., & Rathi, M. M. (2012).
Plasmapheresis in systemic lupus erythematosus with thrombotic microangiopathy.
Internal Medicine Journal, 42(6), 734. doi:10.1111/j.1445-5994.2012.02810.x
Robinson, M., Sheets Cook, ,., & Currie, L. M. (2011). Systemic lupus erythematosus: A
genetic review for advanced practice nurses. Journal Of The American Academy
Of Nurse Practitioners, 23(12), 629-637. doi:10.1111/j.1745-7599.2011.00675.x
Ferenkeh-Koroma, A. (2012). Systemic lupus erythematosus: nurse and patient
education.
Nursing Standard, 26(39), 49-57.
Poole, J. L., Hare, K., Turner-Montez, S., Mendelson, C., & Skipper, B. (2014). Mothers With
Chronic Disease: A Comparison of Parenting in Mothers With Systemic Sclerosis and
Systemic Lupus Erythematosus. OTJR: Occupation, Participation & Health, 34(1), 1219. doi:10.3928/15394492-20131029-06
Christian Pagnoux, C. P. (2007). Plasma exchange for systemic lupus erythematosus.
Transfusion and Apheresis Science , 187-192. Retrieved from
http://vincentbourquin.files.wordpress.com/2009/12/pe-for-sle.pdf
Kang, I., & Park, S. H. (2003). Infectious complications in SLE after immunosuppressive t
herapies. Current opinion in rheumatology, 5, 528–534.
Hari, P., & Srivastava, R. N. Pulse corticosteroid therapy with methylprednisolone or
dexamethasone. Indian journal of pediatrics, 4, 557–560.