14.2 SLE (Systemic Lupus Erythematosus) - Coggle Diagram
14.2 SLE (Systemic Lupus Erythematosus)
Def: a chronic
inflammatory autoimmune disease
that affects almost all body systems, including the musculoskeletal system.
Environmental (viruses, occupational exposure to silica dust, ultraviolet light, cigarette smoking)
Hormonal factors (an imbalance of sex hormones, e.g. women who use estrogen-containing oral contraceptives/ hormone replacement)
autoantibody production results from disordered hyperactive B cells and disorder of T-cell function.
autoantibodies against normal body components.
immune complexes form when autoantibodies bind with their target tissues.
the immune complexes are deposited in connective tissues of blood vessels, lymphatic vessels, and other tissues.
the deposits trigger an inflammatory response with release of destructive enzymes and leading to tissue damage.
Kidney, musculoskeletal system, brain, heart are affected.
unexplained fever, anorexia, extreme fatigue, weight loss, skin manifestations (red butterfly rash across the cheeks and bridge of the nose), scaly, circular lesions
the disease & its potential effects. Promote an optimistic outlook, stressing that the majority of pts do not require long-term corticosteroid therapy and that the disease may improve over time.
the importance of skin care
the importance of avoiding exposure to infection
the need to follow the prescribed treatment plan, including rest & exercise, medications, & follow-up appointments.
discuss manifestations of an acute episode & stress the importance of contacting the physician promptly if any of the manifestations occur.
RISK FOR INFECTION
Wash hands before & after providing direct care. (R) Hand hygiene removes transient organisms from the skin, reducing the risk of transmission to the pt.
Assess pt frequently for infection. Monitor temperature & vital signs every 4 hours.
(R) The pt receiving immunosuppressive therapy for the disease has an even higher risk for infection.
Initiate reverse/ protective isolation procedures as indicated by the pt's immune status.
(R) These procedures provide further protection from infection for the severely immunocompromised pt.
Ensure an adequate nutrient intake, offering supplementary feedings as indicated.
(R) Adequate nutrition is important for healing and immune system function.
Provide care & teaching in a nonjudgmental manner.
(R) To intervene effectively, the nurse must accept the pt and family as they are.
Encourage the pt and family members to discuss the effect of the disease on their lives.
(R) Open discussion helps the pt and the nurse identify barriers to health maintenance and begin exploring alternative strategies.
Initiate an interprofessional care conference w/ the pt and family.
(R) In this care conference, a number of perspectives can be expressed, improving the planning of strategies for health maintenance activities.
Refer the pt and family to counseling as needed.
(R) Counselling may help the pt and family develop the necessary coping skills to accept & deal w/ the disease.
IMPAIRED SKIN INTEGRITY
Assess knowledge of SLE and its possible effects on the skin. (R) Assessment allows the nurse to base teaching & information on the pt's existing knowledge, improving learning & retention
Discuss the relationship btwn sun exposure and disease activity, both dermatologic & systemic.
(R) It's important for the pt to understand that sun exposure may not only cause dermatologic manifestations but also trigger an acute episode.
Keep skin clean & dry; apply therapeutic creams/ ointments to lesions as prescribed.
(R) These measures promote healing & reduce the risk for infection.
Full Blood count
: measures the number of RBC, WBC, platelets & amount of hemoglobin (protein in RBC) ->
low WBC/platelet count
may occur in lupus.
Erythrocyte sedimentation rate
: determines the rate at which RBC settle to the bottom of a tube in an hour. ->
a faster than normal rate
indicate a systemic disease
: assess the severity of renal lesions & guide therapy.
: examine the urine sample ->
increased protein level/ RBC in urine
occurs if lupus has affected the kidneys.
(ANA) Antinuclear antibody test
: a positive test for the presence of antibodies (indicates a stimulated immune system) ->
+ve result indicate ppl have lupus
Serum complement levels
decreased as complement is consumed by the development of antigen-antibody complexes
Anti-DNA antibody testing
specific indicator of SLE*
avoid sun exposure (UV light can trigger disease)
use sunscreens with a (SPF) sun protection factor rating of 15 or higher when outside
Topical corticosteroids: to treat skin lesions
avoiding use of oral contraceptives (estrogen can trigger an acute episode)