Notes

MY NOTES ON LUPUS FROM TEGRITY
Systemic Lupus Erythematous (SLE) -Lupus- (slides 116-136)
Lupus is a chronic multisystem inflammatory autoimmune disease. It is characterized by an unpredictable course with alternating exacerbations and remissions. It is most common in women of child bearing years and more common in african americans, asians, hispanics, and native americans.
etiology is unknown.
Most probable causes:
-genetic influences
-hormonal influence
*this is thought to be a cause because it often onsets after menarche (first period), when women take oral contraceptions, during/after pregnancy, and it tends to worsen in immediate postpartum period.
-Environmental factors
*sun exposure and sun burn are the most common trigger envorinmentally
-Infectious agents may serve as a stimulus, but they have not indentified a specific agent.
-Certain medications
*such as procainamide, hydrolozine, and some anti seizure drugs
Lupus is characterized by the production of a large variety of autoantibodies against nucleic acids. Affects person's own self. It works against the body's proteins. It affects coagulation, giving you either hypo- or hypercoagulation. It affects lymphocytes, giving you decreased immune reactions or activity. It affects platelets, affecting bleeding.
There is an antibody response. circulating immune complexes containing antibody against DNA are deposited in the capillaries of the kidneys, heart, skin, brain, and joints. In this disorder, the kidneys, heart, skin, brain, and joints are affected. When that happens, complement is activated, so there is inflammation in those organs. Ms. Mills says this will be more clear as we continue, but ms. mills is a whore, so who really knows?
SLE Manifestations
-Generalized complaints of fever, weight loss, joint pain, and excessive fatigue may precede an exacerbation.
-Lupus is extremely variable in severity. It ranges from relatively mild to a rapidly progressive disease affecting many organs. The specific manifestations of lupus depend on which cell types or organs are involved.
-There is no characteristic pattern of progression, but it most commonly affects skin, muscles, linings of lungs, heart, nervous tissue, and kidneys.
-Cutaneous vascular lesions (lesions on skin) can appear in any location but most likely in sun exposed areas. about 20% have coin-shaped lesions. Some have persistent lesions, photosensitivity, and mild systemic disease in a syndrome called subcutaneous lupus.
-some have oral or nashopharyngeal ulcers. (33%)
-some have alopecia (hair loss) and there may or may not be skin lesions under that hair. The hair may grow back during remission, but it is sometimes permanent. The scalp becomes dry and scaly, and atrophy.
-You see the butterfly rash in about half the patients.
Clinical Manifestations
**The things you see are related to whatever organ is involved**
-Musculoskeletal. Polyarthralgia with morning stiffness (may last several years before the onset of multisystem lupus), arthritis occurs in many lupus patients but it's nonerosive, swan neck fingers, ulnar deviation, subluxation with hyperlaxity (loose joints), increased risk of bone fracture/loss
-Cardiopulmonary. tachypnea, cough, increased RR, pleurisy, dysrhythmias (typically a sign of advanced disease. can attribute greatly to death), pericarditis (inflammation of pericardium), accelerated coronary artery disease (at risk for coagulation disorder)
-Renal. Scarring and permanent damage can lead to end-stage renal disease. **lupus-nephritis (40% within 5 years of onset ranging from mild proteinuria to glomerularnephritis), primary goal in treatment is slow the progression, treatment typically includes steroid, cytotoxic agents, and immunosupressive agents. steroids are given orally or iv.
-Nervous System. seizures (generally controlled by steroids or anti seizure drugs), peripheral neuropathy (leading to sensory and memory deficits), cognitive dysfunction, psychiatric symptoms/psychotic disorders (mood disorders, anxiety, psychosis), and occasionally stroke and aseptic meningitis has been attributed to lupus, headaches are common.
-Hematologic (blood). anemias, leukopenias (decreased wbcs), thrombocyopenias ( decrease in platelets), some have either hypercoagulation (blood clots too quickly) treated with coumadin or hypocoagultion (bleeding too much).
-Infection. Major cause of death, with puemonia being the most common. increased susceptibility to infection because of the disease the steroids or other medicines you have to take. pts with lupus can only take vaccinations that do not have a live virus.

Diagnostic Studies
There is no specific diagnostic test for lupus. It is diagnosed primarily on criteria relating to patient history like the rash and other manifestations
ANA is present in 97% but is not diagnostics.
The anti-Smith (SM) antibodies are found in 30-40% and are almost always considered diagnostic.
The lupus erthomatosis cell prep (LE cell prep) is still nonspecific because some pts with lupus have a + test, but some don't.
Goal
A major challenge is to manage it actively and prevent complications. That is the goal.
Drug Therapy
-NSAIDs (remember potential GI and renal effects)
-Antimalarial agents (Plaquenil and Aralen) treats fatigue, skin, and joint problems. may take several months to become effective. Plaquenil has a side effect of retinal damage, so they must have regular eye exams.
-Steroid-sparing drugs can control severe exacerbations. immunosuppressants. can be topical (Elidil) treats cutaneous lupus. (Imuran and Cytoxan) used for lupus nephritis or renal involvements
-hypercoagulants (coumadin)
-Corticosteroids
-Biologic and targeted therapy agents are used to interfer with immune response and combat osteroporosis (Orencia)
-hormones to combat lupus induced osteoporosis. (Thalidodide) cutaneous lesions, but only used if pt doesn't respond to other therapies.
Teach pt how to use their drugs, when to take them, the side effects, and if they stop them abruptly, it will lead to an exacerbation.
Nursing Assessment
-subjective data. (exposure to trigger drugs, other triggers, stress, states of increased estrogen activity, oral ulcers, shortness of breath, morning stiffness, fatigue, chest pain, depression, organ involvement)
-objective data (fever, butterfly rash, asopecia, pleural friction rub, dysrthmias, edema, confusion, seizures, proteinuria)
-physical, psychological, and sociocultural problems. (hard time keeping job, fulfilling family duties)
-evaluate the influence of pain and fatigue on ADLs.
Nursing Diagnoses
-Fatigue
-impaired skin integrity
-impaired comfort
Nursing Goals
-Have satisfactory pain management
-Comply with therapeutic regimen to achieve maximum symptom managment
-demonstrate awareness of, and avoid activies that cause, disease exacerbation
-maintain optimal role function and a positive self-image
Health Promotion
Prevention is not possible. We promote early diagnosis and treatment through education of health professionals and the community. The unpredictable nature presents many challenges to everyone.
Who is the multidiscplinary team?
nurse, patient, hcp, physical therapy, occupational therapy, pharmicist, case manager, social interventions, psychiatrist/psychologist, specialists depending on what organ is involved
During exacerbation, the patient with become abrupty, dramatically ill and the nurse will need to record severity and response to therapy. This will put the patient in the hospital.
Acute interventions
observe for signs of bleeding, fever pattern, joint inflammation and limitation of motion, location and degree of discomfort and fatige. monitor weight, I&O especially if steroids are prescribed,
24 hour urine sample, neurological status, visual disturbanes, headaches, seizures, personality changes, forgetfulness, irritation of nerves, numbness, tingling, weakness, and provide support, treatment options, and diagnostic procedures.
Patient teaching
Teach patient that although the course of the disease is unpredictable, a variety of factors may increase disease activity like fatigure, sun exposure, stress, drugs, and surgery.
Emphasize the importance of patient cooperation for successful home management. minimize exposure to triggers. infertility can result from steroids, renal involvment, and chemo drugs. spontaneous abortion, still birth, and intrauteran growth retardation is common (small weight baby), for the best outcome, pregnancy should be planned when disease activity is minimal and has to be told that exacerbation will probably happen after birth. psychosocial issues result in fear, so they must be counseled so they know what to expect and how to minimize effects. rest often. don't overtire yourself. they must avoid sunlight as much as possible.
Expected Outcomes
-use energy conservation techniques
-adapt lifestyle to energy level (may need to cut back on strenous activity)
-maintain skin integrity with the use of topical treatments
-prevent exacerbations with the use of sunscreens and limited sun exposure
MS. MILLS' END OF LECTURE NOTES ON LUPUS
systemic inflammatory autoimmune with remissions and exacerbations
genetics with a trigger
butterfly rash, discoid rash, whichever organ is involved, alopecia, nonerosive arthritis, low wbc, anemias, hypo or hyper coagulation, psychotic disorders, photosensitivity, hormone involvement
infection is a major cause of death.
anti smith antibodies
NSAIDs, immunosuppresants, antimalarials
no prevention

QUESTIONS
1.) What is lupus?
Lupus is a chronic multisystem inflammatory autoimmune disease.
2.) What is it characterized by?
an unpredictable course with alternating exacerbations and remissions.
3.) Who does it most commonly affect?
It is most common in women of child bearing years and more common in african americans, asians, hispanics, and native americans.
4.) What causes lupus?
The cause is unknown, but its most probable causes are:
-genetic influences
-hormonal influence
*this is thought to be a cause because it often onsets after menarche (first period), when women take oral contraceptions, during/after pregnancy, and it tends to worsen in immediate postpartum period.
-Environmental factors
*sun exposure and sun burn are the most common trigger envorinmentally
-Infectious agents may serve as a stimulus, but they have not indentified a specific agent.
-Certain medications
*such as procainamide, hydrolozine, and some anti seizure drugs
5.) What actually happens in lupus?
There is the production of a large variety of autoantibodies against nucleic acids. Affects person's own self. It works against the body's proteins. It affects coagulation, giving you either hypo- or hypercoagulation. It affects lymphocytes, giving you decreased immune reactions or activity. It affects platelets, affecting bleeding.
There is an antibody response. circulating immune complexes containing antibody against DNA are deposited in the capillaries of the kidneys, heart, skin, brain, and joints. In this disorder, the kidneys, heart, skin, brain, and joints are affected. When that happens, complement is activated, so there is inflammation in those organs.
6.) What are the physical manifestations in lupus?
-Generalized complaints of fever, weight loss, joint pain, and excessive fatigue may precede an exacerbation.
-Lupus is extremely variable in severity. It ranges from relatively mild to a rapidly progressive disease affecting many organs. The specific manifestations of lupus depend on which cell types or organs are involved.
-There is no characteristic pattern of progression, but it most commonly affects skin, muscles, linings of lungs, heart, nervous tissue, and kidneys.
-Cutaneous vascular lesions (lesions on skin) can appear in any location but most likely in sun exposed areas. about 20% have coin-shaped lesions. Some have persistent lesions, photosensitivity, and mild systemic disease in a syndrome called subcutaneous lupus.
-some have oral or nashopharyngeal ulcers. (33%)
-some have alopecia (hair loss) and there may or may not be skin lesions under that hair. The hair may grow back during remission, but it is sometimes permanent. The scalp becomes dry and scaly, and atrophy.
-You see the butterfly rash in about half the patients.
7.) How does lupus affect each body system?
**The things you see are related to whatever organ is involved**
-Musculoskeletal. Polyarthralgia with morning stiffness (may last several years before the onset of multisystem lupus), arthritis occurs in many lupus patients but it's nonerosive, swan neck fingers, ulnar deviation, subluxation with hyperlaxity (loose joints), increased risk of bone fracture/loss
-Cardiopulmonary. tachypnea, cough, increased RR, pleurisy, dysrhythmias (typically a sign of advanced disease. can attribute greatly to death), pericarditis (inflammation of pericardium), accelerated coronary artery disease (at risk for coagulation disorder)
-Renal. Scarring and permanent damage can lead to end-stage renal disease. **lupus-nephritis (40% within 5 years of onset ranging from mild proteinuria to glomerularnephritis), primary goal in treatment is slow the progression, treatment typically includes steroid, cytotoxic agents, and immunosupressive agents. steroids are given orally or iv.
-Nervous System. seizures (generally controlled by steroids or anti seizure drugs), peripheral neuropathy (leading to sensory and memory deficits), cognitive dysfunction, psychiatric symptoms/psychotic disorders (mood disorders, anxiety, psychosis), and occasionally stroke and aseptic meningitis has been attributed to lupus, headaches are common.
-Hematologic (blood). anemias, leukopenias (decreased wbcs), thrombocyopenias ( decrease in platelets), some have either hypercoagulation (blood clots too quickly) treated with coumadin or hypocoagultion (bleeding too much).
-Infection. Major cause of death, with puemonia being the most common. increased susceptibility to infection because of the disease the steroids or other medicines you have to take.
8.) What studies are used to diagnose lupus?
There is no specific diagnostic test for lupus. It is diagnosed primarily on criteria relating to patient history like the rash and other manifestations
ANA is present in 97% but is not diagnostics.
The anti-Smith (SM) antibodies are found in 30-40% and are almost always considered diagnostic.
The lupus erthomatosis cell prep (LE cell prep) is still nonspecific because some pts with lupus have a + test, but some don't.
9.) What is the drug therapy for lupus?
-NSAIDs (remember potential GI and renal effects)
-Antimalarial agents (Plaquenil and Aralen) treats fatigue, skin, and joint problems. may take several months to become effective. Plaquenil has a side effect of retinal damage, so they must have regular eye exams.
-Steroid-sparing drugs can control severe exacerbations. immunosuppressants. can be topical (Elidil) treats cutaneous lupus. (Imuran and Cytoxan) used for lupus nephritis or renal involvements
-hypercoagulants (coumadin)
-Corticosteroids
-Biologic and targeted therapy agents are used to interfer with immune response and combat osteroporosis (Orencia)
-hormones to combat lupus induced osteoporosis. (Thalidodide) cutaneous lesions, but only used if pt doesn't respond to other therapies.
Teach pt how to use their drugs, when to take them, the side effects, and if they stop them abruptly, it will lead to an exacerbation.
10.) What do you include in your nursing assessment for lupus?
-subjective data. (exposure to trigger drugs, other triggers, stress, states of increased estrogen activity, oral ulcers, shortness of breath, morning stiffness, fatigue, chest pain, depression, organ involvement)
-objective data (fever, butterfly rash, asopecia, pleural friction rub, dysrthmias, edema, confusion, seizures, proteinuria)
-physical, psychological, and sociocultural problems. (hard time keeping job, fulfilling family duties)
-evaluate the influence of pain and fatigue on ADLs.
11.) What are some possible nursing diagnoses?
-Fatigue
-impaired skin integrity
-impaired comfort
12.) How can promote health concerning lupus?
Prevention is not possible. We promote early diagnosis and treatment through education of health professionals and the community. The unpredictable nature presents many challenges to everyone.
13.) What are our nursing goals when treating lupus?
-Have satisfactory pain management
-Comply with therapeutic regimen to achieve maximum symptom managment
-demonstrate awareness of, and avoid activies that cause, disease exacerbation
-maintain optimal role function and a positive self-image
14.) Who is involved in a lupus exacerbation? (multidiscplinary team)
nurse, patient, hcp, physical therapy, occupational therapy, pharmicist, case manager, social interventions, psychiatrist/psychologist, specialists depending on what organ is involved.
15.) What happens in an exacerbation?
During exacerbation, the patient with become abrupty, dramatically ill and the nurse will need to record severity and response to therapy. This will put the patient in the hospital.
16.) What are some acute interventions for lupus?
observe for signs of bleeding, fever pattern, joint inflammation and limitation of motion, location and degree of discomfort and fatige. monitor weight, I&O especially if steroids are prescribed,
24 hour urine sample, neurological status, visual disturbanes, headaches, seizures, personality changes, forgetfulness, irritation of nerves, numbness, tingling, weakness, and provide support, treatment options, and diagnostic procedures.
17.) What do you include in patient teaching for a patient with lupus?
Teach patient that although the course of the disease is unpredictable, a variety of factors may increase disease activity like fatigure, sun exposure, stress, drugs, and surgery.
Emphasize the importance of patient cooperation for successful home management. minimize exposure to triggers. infertility can result from steroids, renal involvment, and chemo drugs. spontaneous abortion, still birth, and intrauteran growth retardation is common (small weight baby), for the best outcome, pregnancy should be planned when disease activity is minimal and has to be told that exacerbation will probably happen after birth. psychosocial issues result in fear, so they must be counseled so they know what to expect and how to minimize effects. rest often. don't overtire yourself. they must avoid sunlight as much as possible.
18.) What are the expected outcomes for a patient with lupus?
-use energy conservation techniques
-adapt lifestyle to energy level (may need to cut back on strenous activity)
-maintain skin integrity with the use of topical treatments
-prevent exacerbations with the use of sunscreens and limited sun exposure