logging in or signing up Lupus.audio.2010 tom.oertel Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 185 Category: Education License: All Rights Reserved Like it (0) Dislike it (1) Added: November 17, 2010 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Lupus Erythematosus: Living with a Chronic Condition : Lupus Erythematosus: Living with a Chronic Condition Canis Lupus Thomas Oertel DNP RN NURS 203 Slide 2: Figure 20-8. Mechanisms of autoimmunityGo back tutor.lscf.ucsb.edu/. ../figure20-05.htm Slide 3: Mechanisms of Autoimmune DiseasesWith the mouse, , move the pointer to the disease (in red) and click to find out more. tutor.lscf.ucsb.edu/. ../figure20-05.htm What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? SLE is a multisystem, autoimmune disorder: there is an abnormal or overactive regulation of the attack response the body’s immune system recognizes its own tissue as a “self-antigen” and attacks itself through the development of “autoantibodies.” The “autoantibodies” of SLE attack the cell nucleus, esp. the DNA. This will explain the damage to many organs and tissues Slide 6: Lupus Erythematosus The immune complexes also circulate to various organs and are deposited in connective tissue, initiating an inflammatory response Lupus: Joints, kidneys, brain, heart, etc What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? The effects are typically on connective and vascular tissues with chronic inflammatory characteristics; the inflammation decreases organ function and/or causes pain Therefore, SLE is considered a “rheumatoid” and a “collagen vascular” disease; SLE pts are treated by rheumatologists What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? SLE is characterized by periods of remission and exacerbation; an unpredictable course. Acute exacerbations are caused by triggers. [discussed later] Because of the wide range of signs and symptoms, SLE is often misdiagnosed. What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? Women of childbearing age [women:men = 10:1]: women naturally have more immune response than men we will see that many other autoimmune diseases also occur to women African American and Latin women are at higher risk Children of women with SLE: 5% of newborns of SLE women will also develop SLE (genetic or random chance?) What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? Lupus worldwide is more prevalent than leukemia, muscular dystrophy and multiple sclerosis. Afro-Caribbeans, Asians and Far Eastern races are more prone to having lupus. In lupus, a variety of autoantibodies are produced against which attack which organ systems? : In lupus, a variety of autoantibodies are produced against which attack which organ systems? In lupus, a variety of autoantibodies are produced against which attack which organ systems? : In lupus, a variety of autoantibodies are produced against which attack which organ systems? Primarily: (affects the cell nucleus of) The skin Joints Blood Kidneys Nerves and central nervous system/brain May affect almost all organs/systems What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? One or more triggers can set off the illness in people who may have susceptibility to lupus. Stress and fatigue [a common problem in all autoimmune diseases!]: emotional, childrearing, surgery, nursing school, etc. Sunlight [can cause a major exacerbation]: possibly sunlight changes a protein as it passes through blood vessels in the skin; the changed proteins then initiate an abnormal immune response What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? One or more triggers can set off the illness in people who may have susceptibility to lupus. Hormonal changes: at puberty during the menopause during pregnancy or after childbirth after viral infection or infections in general What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? Lupus is often triggered in people where there is family history of lupus and/or other immune system illnesses such as arthritis, MS, Raynaud’s disease, and rheumatoid arthritis. Differing environmental factors may also contribute to the initiation of the illness in some patients. Lupus is neither infectious nor contagious. What are some medications that promote lupus-like attacks? : What are some medications that promote lupus-like attacks? What are some medications that promote lupus-like attacks? : What are some medications that promote lupus-like attacks? Not true SLE: a drug-induced lupus; D/C med and the signs/symptoms typically disappear Estrogen [e.g. birth control pills and hormone replacement therapy] Procainamide Hydralazine Isoniazid (INH) Sulfa Many, many others! These same meds should not be given to a pt with SLE to prevent an exacerbation! The clinical manifestations of lupus by system : The clinical manifestations of lupus by system According to the AJN article, what is the most common symptom of lupus? : According to the AJN article, what is the most common symptom of lupus? According to the AJN article, what is the most common symptom of lupus? : According to the AJN article, what is the most common symptom of lupus? Joint pain: either in single or multiple joints, is the presenting symptom most frequently reported. According to the AJN article, what are the other common symptoms of lupus? : According to the AJN article, what are the other common symptoms of lupus? Photosensitivity = 43% “Butterfly/malar” rash on face = 50% Other: fatigue, Raynaud’s phenomenon [attacks of painful, ischemic hands with cold exposure], chronic or recurrent fevers, hair loss, weakness, weight loss System involvement [next slides] What systems are involved in SLE? : What systems are involved in SLE? joints/skeletal : joints/skeletal 90-95% of pts with SLE complain of joint pain and actual arthritic symptoms Generally non-deforming swelling Digital ulcers Multiple joint morning stiffness Arthritis [joint pain] occurs in 95% of SLE pts; sometimes with classic arthritic changes (swan-neck deformity of hands, ulnar deviation of wrist, etc.) Myositis, Synovitis Skin/dermatologic : Skin/dermatologic 50% have butterfly/malar rash “fixed erythema, flat or raised, not present on nasolabial folds” Red rash across cheeks and bridge of nose, not above eyes or between mouth and nose; may involve chest and upper arms Photosensitive rash on exposed areas 75-85% of all LE pts have some skin Sx Slide 29: Butterfly/malar rash across cheeks and bridge of nose; Eyes and below nose are not involved; Acne does not affect bridge of nose What is the difference between discoid lupus and systemic lupus? : What is the difference between discoid lupus and systemic lupus? What is the difference between discoid lupus and systemic lupus? : What is the difference between discoid lupus and systemic lupus? Discoid lupus is rarely systemic but rather causes disfiguring “discoid patches” anywhere on the body, particularly on the face. Lesions (patches and craters) may produce scarring or atrophy. Scarring alopecia is particularly disturbing. Slide 32: Discoid Lupus can be disfiguring Slide 33: The British performer, Seal, has discoid lupus that has left scars on his face. Slide 34: Chronic discoid lupus can leave scarring and disfigurement. Slide 35: Discoid lesions can occur anywhere on the body Slide 36: Rarely, people with DLE also have circulatory problems. They may have Raynaud's - this refers to abnormal blanching of fingers and toes in response to cold weather, followed by numbness and slow rewarming by the fingers which go blue then red. They may have mild arthritis in their hands. Slide 37: Alopecia [hair loss] (above) and vitiligo [abnormal loss of pigmentation] (right) are also associated with lupus. Slide 38: Palmar erythema, vasculitis and digital (finger) ulcers can also be signs of SLE Clinical manifestations of lupus: Renal : Clinical manifestations of lupus: Renal 50% of SLE pts develop renal complications: from mild to ESRD (End Stage Renal Disease) Glomerulonephritis is the end result of the effects of lupus on the kidney Signs: proteinuria (3+; 500mg – 3Gm protein/d) cellular casts (destruction of basement membrane causing sloughing of epithelium (casts); it is rare to see casts on a Urinalysis! Clinical manifestations of lupus: hematologic : Clinical manifestations of lupus: hematologic Remember: lupus attacks the nucleus of all cells including the blood forming cells 50% of SLE pts have hematologic signs on a routine CBC RBC: anemia fatigue WBC: leukopenia infections platelets: thrombocytopenia risk for bleeding Clinical manifestations of lupus: heart and lung : Clinical manifestations of lupus: heart and lung 30% develop complications of the irritation and inflammation of the serous membrane/lining of the heart, pleura, and pericardium Pleurisy, pericarditis, pleural effusions, pleural rubs Sx: chest pain, SOB, atypical pneumonia, arrhythmias, pleural effusions Clinical manifestations of lupus: neuro/psych : Clinical manifestations of lupus: neuro/psych 10-20% develop neuro/psych problems Seizures, psychosis, stroke, OMD, paralysis, migraines, cognitive changes In one state mental hospital, 30% of pts had (+) test for lupus Clinical manifestations of lupus: oral/GI : Clinical manifestations of lupus: oral/GI Painless oral and nasopharyngeal ulcerations can affect nutrition SLE is called “the great pretender” because of its many signs and symptoms Slide 45: Oral lesions of lupus What is the long-term prognosis for pts with lupus? : What is the long-term prognosis for pts with lupus? What is the long-term prognosis for pts with lupus? : What is the long-term prognosis for pts with lupus? Most pts live normal lives with current Tx. The number of systems involved and the severity of the involvement determine the outcome/prognosis. What are the usual causes of death in SLE? : What are the usual causes of death in SLE? What are the usual causes of death in SLE? : What are the usual causes of death in SLE? Lupus nephritis is a leading cause of death r/t end-stage renal failure Other causes: Pneumonia Septicemia Diagnostic tests for SLE : Diagnostic tests for SLE Antinuclear Antibody (ANA) test : Antinuclear Antibody (ANA) test 99% of SLE pts have (+() ANA Good screening test for autoimmune diseases more specific tests done if (+) Antibodies against cell nuclei are pathologic for SLE LE (lupus erythematosus) cell prep : LE (lupus erythematosus) cell prep The original test for SLE: a real milestone in the Dx of SLE Less specificity than ANA Rarely done alone Anti-DNA antibodies : Anti-DNA antibodies Anti-DNA is more specific than ANA Rarely false (-) in SLE Sometimes false (+) in pt without SLE Part of a Lupus Panel Helpful in monitoring response to Tx Anti-Sm antibody : Anti-Sm antibody An antibody to the Smith nuclear antigen Definitive serologic marker for SLE Not (+) in other rheumatic diseases Serologic test for syphilis (VDRL or RPR) : Serologic test for syphilis (VDRL or RPR) Often (+) in pts with SLE a false (+) The patient does not have syphilis a (+) needs to be explained the pt and significant others (when needed) Complete Blood Count (CBC) : Complete Blood Count (CBC) Anemia (98% of pts) Mild Leukopenia (80%) Thrombocytopenia (36%) Erythrocyte Sedimentation Rate (ESR): : Erythrocyte Sedimentation Rate (ESR): If “prolonged” (higher results), indicates inflammation Helpful in monitoring response to Tx Urinalysis (Routine UA) : Urinalysis (Routine UA) Indicators of SLE glomerulonephritis: Proteinuria Casts Kidney function tests (e.g. creatinine) : Kidney function tests (e.g. creatinine) Abnormal values, e.g. serum creatinine, may indicate renal damage What are the general goals of treatment? : What are the general goals of treatment? What are the general goals of treatment? : What are the general goals of treatment? There is no cure Control the abnormal immune and limit the inflammation in order to control symptoms and remain in remission (though some Sx may persist) Limit organ damage and disease progression (takes a lot of pt education) Pharmacology for SLE : Pharmacology for SLE NSAIDs (e.g. Ibuprofen, Naproxen) : NSAIDs (e.g. Ibuprofen, Naproxen) Indication: inflammatory process, esp in joints; a common medication for SLE Side-effects: GI upset/bleed; nephrotoxic (e.g. Feldene) renal insufficiency/acute renal failure; bleeding Plaquenil (hydroxychloroquine) : Plaquenil (hydroxychloroquine) Indication: an antimalarial with inflammatory effect, esp in skin & joints Side-effects: Potential retinal damage retinal exam Q6 months Skin rash GI upset Steroids : Steroids Indication: potent antiinflammatory and immune suppression actions used for acute exacerbations and serious complications Side-effects: many, including GI bleed, hyperglycemia and immunocompromise Indication: steroid cream (topical) used for rash (few side-effects, except hypo-pigmentation for some creams Immunosuppressive Medications : Immunosuppressive Medications Examples: Imuran (azathioprine) and Cytoxan (cyclophosphamide): where else are they used? Immunosuppressive Medications : Immunosuppressive Medications Examples: Imuran (azathioprine) and Cytoxan (cyclophosphamide): where else are they used? Imuran (azathioprine): used for Crohn’s disease as immunosuppressive Cytoxan (cyclophosphamide): used as chemotherapy with immunosuppressive side-effects; in SLE, lower dosages are used for the immunosuppressive effects Immunosuppressive Medications : Immunosuppressive Medications Indication: suppress abnormal immune system that is creating abnormal autoantibodies and other factors that lead to inflammation and organ damage Side-effects: many, especially immunocompromise with high risk for infections; also hepatotoxicity, bone marrow suppression, pancreatitis Nursing Care for the SLE Patient : Nursing Care for the SLE Patient Lupus is characterized by fatigue. What are some steps that the pt can be taught to address the fatigue? : Lupus is characterized by fatigue. What are some steps that the pt can be taught to address the fatigue? What are some steps that the pt can be taught to address the fatigue? : What are some steps that the pt can be taught to address the fatigue? Adequate rest at night and naps is encouraged; “don’t overdo it!” Bedrest during exacerbations fatigue may be a warning Sx of impending exacerbation Plan activities and ADLs around times when pt has most energy (e.g. AM) Ask for help! With kids, housework, etc. Sit rather than stand to do activities Discuss the pt education for care of the skin and the protection of the skin from the sun. Why is protection from the sun so important for the lupus pt? : Discuss the pt education for care of the skin and the protection of the skin from the sun. Why is protection from the sun so important for the lupus pt? Why is protection from the sun so important for the lupus pt? : Why is protection from the sun so important for the lupus pt? Exposure to the sun has the potential to exacerbate lupus and aggravate symptoms Discuss the pt education for care of the skin and the protection of the skin from the sun. : Discuss the pt education for care of the skin and the protection of the skin from the sun. Protective clothing outside (long sleeves, broad brimmed hats, high collar, long trousers or skirt, socks and shoes Avoid sun in the midday (10am-2pm) Use sunscreen (high SPF) Avoid meds that sun sensitivity (tetracycline, sulfa, phenothiazines, others) Cosmetics: consult make-up professionals for products that will allow pts to go outside without embarrassment Preventive measures when the pt is at risk for infection : Preventive measures when the pt is at risk for infection Immunocompromise risk for infection Avoid large crowds Avoid situations where exposure to infection is possible, e.g. daycare Good handwashing If very neutropenic: reverse isolation (private room; masks to protect the pt, not the nurse; no flowers) The effects of pregnancy on lupus : The effects of pregnancy on lupus ½ of SLE women who are pregnant feel no change; ½ either feel better or become worse Most exacerbations occur in first trimester or in the immediate postpartum or post- abortion period Women with SLE can successfully bear children and deliver children: best if planned, during a remission, and the woman has good medical care The effects of pregnancy on lupus : The effects of pregnancy on lupus Women with serious organ disease r/t SLE (kidney, heart, CNS) should consult with MD and may be counseled against pregnancy Lupus mothers are at higher risk for toxemia and miscarriage the effects of lupus on the fertility and complications of pregnancy : the effects of lupus on the fertility and complications of pregnancy Fertility is normal when SLE is in remission Lupus is not considered hereditary There is an risk for spontaneous miscarriage, stillbirth, prematurity and low birth weight birth control measures for female pts with lupus : birth control measures for female pts with lupus Estrogen BCP: IUD (Intrauterine device): Barrier method: Birth control measures for female pts with lupus : Birth control measures for female pts with lupus Estrogen BCP: can exacerbate lupus IUD (Intrauterine device): risk for infection Irritant on uterine wall with risk for bleeding Barrier method: Best (none of the above problems) with diaphragm and condom with spermicidal jelly the signs of an acute lupus attack to teach the pt and family : the signs of an acute lupus attack to teach the pt and family severity of joint pain, swelling, fatigue, rashes, mouth ulcers, alopecia, pleuritic chest pain, shortness of breath Outline measures to promote nutrition related to fatigue, nausea and oral ulcerations : Outline measures to promote nutrition related to fatigue, nausea and oral ulcerations What are your ideas for these? Fatigue: Nausea: Oral ulcerations: Patient and Family Education (Summary) : Patient and Family Education (Summary) Education on the disease process Meds: names, actions, dosages, times, side-effects Energy conservation and pacing techniques Daily exercise and joint management Avoid triggers: physical and emotional stress, overexposure to ultraviolet light/sun, exposure to infection Patient and Family Education (Summary) : Patient and Family Education (Summary) 7. Regular medical and lab follow-up 8. Marital/fertility counseling, if needed 9. Referral to community resources and health care agencies Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Lupus: A Patient Care Guide for Nurses and Other Health Professionals Care of the Lupus Patient (sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of National Institutes of Health (NIH) lupus guide for nurses Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Systemic Lupus Erythematosus, (sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of National Institutes of Health (NIH) systemic lupus erythematosus Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Nursing Diagnoses for the LE Patient : Nursing Diagnoses for the LE Patient Fatigue with Activity Intolerance Chronic or Acute Pain Body Image Disturbance Altered Sexuality (Fertility) Altered Nutrition, less than Body Requirements Ineffective management of therapeutic regimen Slide 90: How best can we deliver nursing care to this SLE pt? You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Lupus.audio.2010 tom.oertel Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 185 Category: Education License: All Rights Reserved Like it (0) Dislike it (1) Added: November 17, 2010 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Lupus Erythematosus: Living with a Chronic Condition : Lupus Erythematosus: Living with a Chronic Condition Canis Lupus Thomas Oertel DNP RN NURS 203 Slide 2: Figure 20-8. Mechanisms of autoimmunityGo back tutor.lscf.ucsb.edu/. ../figure20-05.htm Slide 3: Mechanisms of Autoimmune DiseasesWith the mouse, , move the pointer to the disease (in red) and click to find out more. tutor.lscf.ucsb.edu/. ../figure20-05.htm What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? SLE is a multisystem, autoimmune disorder: there is an abnormal or overactive regulation of the attack response the body’s immune system recognizes its own tissue as a “self-antigen” and attacks itself through the development of “autoantibodies.” The “autoantibodies” of SLE attack the cell nucleus, esp. the DNA. This will explain the damage to many organs and tissues Slide 6: Lupus Erythematosus The immune complexes also circulate to various organs and are deposited in connective tissue, initiating an inflammatory response Lupus: Joints, kidneys, brain, heart, etc What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? The effects are typically on connective and vascular tissues with chronic inflammatory characteristics; the inflammation decreases organ function and/or causes pain Therefore, SLE is considered a “rheumatoid” and a “collagen vascular” disease; SLE pts are treated by rheumatologists What are the general characteristics of SLE (systemic lupus erythematosus)? : What are the general characteristics of SLE (systemic lupus erythematosus)? SLE is characterized by periods of remission and exacerbation; an unpredictable course. Acute exacerbations are caused by triggers. [discussed later] Because of the wide range of signs and symptoms, SLE is often misdiagnosed. What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? Women of childbearing age [women:men = 10:1]: women naturally have more immune response than men we will see that many other autoimmune diseases also occur to women African American and Latin women are at higher risk Children of women with SLE: 5% of newborns of SLE women will also develop SLE (genetic or random chance?) What gender and racial groups are at greater risk for LE (lupus erythematosus)? : What gender and racial groups are at greater risk for LE (lupus erythematosus)? Lupus worldwide is more prevalent than leukemia, muscular dystrophy and multiple sclerosis. Afro-Caribbeans, Asians and Far Eastern races are more prone to having lupus. In lupus, a variety of autoantibodies are produced against which attack which organ systems? : In lupus, a variety of autoantibodies are produced against which attack which organ systems? In lupus, a variety of autoantibodies are produced against which attack which organ systems? : In lupus, a variety of autoantibodies are produced against which attack which organ systems? Primarily: (affects the cell nucleus of) The skin Joints Blood Kidneys Nerves and central nervous system/brain May affect almost all organs/systems What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? One or more triggers can set off the illness in people who may have susceptibility to lupus. Stress and fatigue [a common problem in all autoimmune diseases!]: emotional, childrearing, surgery, nursing school, etc. Sunlight [can cause a major exacerbation]: possibly sunlight changes a protein as it passes through blood vessels in the skin; the changed proteins then initiate an abnormal immune response What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? One or more triggers can set off the illness in people who may have susceptibility to lupus. Hormonal changes: at puberty during the menopause during pregnancy or after childbirth after viral infection or infections in general What are some known factors/triggers that promote lupus attacks? : What are some known factors/triggers that promote lupus attacks? Lupus is often triggered in people where there is family history of lupus and/or other immune system illnesses such as arthritis, MS, Raynaud’s disease, and rheumatoid arthritis. Differing environmental factors may also contribute to the initiation of the illness in some patients. Lupus is neither infectious nor contagious. What are some medications that promote lupus-like attacks? : What are some medications that promote lupus-like attacks? What are some medications that promote lupus-like attacks? : What are some medications that promote lupus-like attacks? Not true SLE: a drug-induced lupus; D/C med and the signs/symptoms typically disappear Estrogen [e.g. birth control pills and hormone replacement therapy] Procainamide Hydralazine Isoniazid (INH) Sulfa Many, many others! These same meds should not be given to a pt with SLE to prevent an exacerbation! The clinical manifestations of lupus by system : The clinical manifestations of lupus by system According to the AJN article, what is the most common symptom of lupus? : According to the AJN article, what is the most common symptom of lupus? According to the AJN article, what is the most common symptom of lupus? : According to the AJN article, what is the most common symptom of lupus? Joint pain: either in single or multiple joints, is the presenting symptom most frequently reported. According to the AJN article, what are the other common symptoms of lupus? : According to the AJN article, what are the other common symptoms of lupus? Photosensitivity = 43% “Butterfly/malar” rash on face = 50% Other: fatigue, Raynaud’s phenomenon [attacks of painful, ischemic hands with cold exposure], chronic or recurrent fevers, hair loss, weakness, weight loss System involvement [next slides] What systems are involved in SLE? : What systems are involved in SLE? joints/skeletal : joints/skeletal 90-95% of pts with SLE complain of joint pain and actual arthritic symptoms Generally non-deforming swelling Digital ulcers Multiple joint morning stiffness Arthritis [joint pain] occurs in 95% of SLE pts; sometimes with classic arthritic changes (swan-neck deformity of hands, ulnar deviation of wrist, etc.) Myositis, Synovitis Skin/dermatologic : Skin/dermatologic 50% have butterfly/malar rash “fixed erythema, flat or raised, not present on nasolabial folds” Red rash across cheeks and bridge of nose, not above eyes or between mouth and nose; may involve chest and upper arms Photosensitive rash on exposed areas 75-85% of all LE pts have some skin Sx Slide 29: Butterfly/malar rash across cheeks and bridge of nose; Eyes and below nose are not involved; Acne does not affect bridge of nose What is the difference between discoid lupus and systemic lupus? : What is the difference between discoid lupus and systemic lupus? What is the difference between discoid lupus and systemic lupus? : What is the difference between discoid lupus and systemic lupus? Discoid lupus is rarely systemic but rather causes disfiguring “discoid patches” anywhere on the body, particularly on the face. Lesions (patches and craters) may produce scarring or atrophy. Scarring alopecia is particularly disturbing. Slide 32: Discoid Lupus can be disfiguring Slide 33: The British performer, Seal, has discoid lupus that has left scars on his face. Slide 34: Chronic discoid lupus can leave scarring and disfigurement. Slide 35: Discoid lesions can occur anywhere on the body Slide 36: Rarely, people with DLE also have circulatory problems. They may have Raynaud's - this refers to abnormal blanching of fingers and toes in response to cold weather, followed by numbness and slow rewarming by the fingers which go blue then red. They may have mild arthritis in their hands. Slide 37: Alopecia [hair loss] (above) and vitiligo [abnormal loss of pigmentation] (right) are also associated with lupus. Slide 38: Palmar erythema, vasculitis and digital (finger) ulcers can also be signs of SLE Clinical manifestations of lupus: Renal : Clinical manifestations of lupus: Renal 50% of SLE pts develop renal complications: from mild to ESRD (End Stage Renal Disease) Glomerulonephritis is the end result of the effects of lupus on the kidney Signs: proteinuria (3+; 500mg – 3Gm protein/d) cellular casts (destruction of basement membrane causing sloughing of epithelium (casts); it is rare to see casts on a Urinalysis! Clinical manifestations of lupus: hematologic : Clinical manifestations of lupus: hematologic Remember: lupus attacks the nucleus of all cells including the blood forming cells 50% of SLE pts have hematologic signs on a routine CBC RBC: anemia fatigue WBC: leukopenia infections platelets: thrombocytopenia risk for bleeding Clinical manifestations of lupus: heart and lung : Clinical manifestations of lupus: heart and lung 30% develop complications of the irritation and inflammation of the serous membrane/lining of the heart, pleura, and pericardium Pleurisy, pericarditis, pleural effusions, pleural rubs Sx: chest pain, SOB, atypical pneumonia, arrhythmias, pleural effusions Clinical manifestations of lupus: neuro/psych : Clinical manifestations of lupus: neuro/psych 10-20% develop neuro/psych problems Seizures, psychosis, stroke, OMD, paralysis, migraines, cognitive changes In one state mental hospital, 30% of pts had (+) test for lupus Clinical manifestations of lupus: oral/GI : Clinical manifestations of lupus: oral/GI Painless oral and nasopharyngeal ulcerations can affect nutrition SLE is called “the great pretender” because of its many signs and symptoms Slide 45: Oral lesions of lupus What is the long-term prognosis for pts with lupus? : What is the long-term prognosis for pts with lupus? What is the long-term prognosis for pts with lupus? : What is the long-term prognosis for pts with lupus? Most pts live normal lives with current Tx. The number of systems involved and the severity of the involvement determine the outcome/prognosis. What are the usual causes of death in SLE? : What are the usual causes of death in SLE? What are the usual causes of death in SLE? : What are the usual causes of death in SLE? Lupus nephritis is a leading cause of death r/t end-stage renal failure Other causes: Pneumonia Septicemia Diagnostic tests for SLE : Diagnostic tests for SLE Antinuclear Antibody (ANA) test : Antinuclear Antibody (ANA) test 99% of SLE pts have (+() ANA Good screening test for autoimmune diseases more specific tests done if (+) Antibodies against cell nuclei are pathologic for SLE LE (lupus erythematosus) cell prep : LE (lupus erythematosus) cell prep The original test for SLE: a real milestone in the Dx of SLE Less specificity than ANA Rarely done alone Anti-DNA antibodies : Anti-DNA antibodies Anti-DNA is more specific than ANA Rarely false (-) in SLE Sometimes false (+) in pt without SLE Part of a Lupus Panel Helpful in monitoring response to Tx Anti-Sm antibody : Anti-Sm antibody An antibody to the Smith nuclear antigen Definitive serologic marker for SLE Not (+) in other rheumatic diseases Serologic test for syphilis (VDRL or RPR) : Serologic test for syphilis (VDRL or RPR) Often (+) in pts with SLE a false (+) The patient does not have syphilis a (+) needs to be explained the pt and significant others (when needed) Complete Blood Count (CBC) : Complete Blood Count (CBC) Anemia (98% of pts) Mild Leukopenia (80%) Thrombocytopenia (36%) Erythrocyte Sedimentation Rate (ESR): : Erythrocyte Sedimentation Rate (ESR): If “prolonged” (higher results), indicates inflammation Helpful in monitoring response to Tx Urinalysis (Routine UA) : Urinalysis (Routine UA) Indicators of SLE glomerulonephritis: Proteinuria Casts Kidney function tests (e.g. creatinine) : Kidney function tests (e.g. creatinine) Abnormal values, e.g. serum creatinine, may indicate renal damage What are the general goals of treatment? : What are the general goals of treatment? What are the general goals of treatment? : What are the general goals of treatment? There is no cure Control the abnormal immune and limit the inflammation in order to control symptoms and remain in remission (though some Sx may persist) Limit organ damage and disease progression (takes a lot of pt education) Pharmacology for SLE : Pharmacology for SLE NSAIDs (e.g. Ibuprofen, Naproxen) : NSAIDs (e.g. Ibuprofen, Naproxen) Indication: inflammatory process, esp in joints; a common medication for SLE Side-effects: GI upset/bleed; nephrotoxic (e.g. Feldene) renal insufficiency/acute renal failure; bleeding Plaquenil (hydroxychloroquine) : Plaquenil (hydroxychloroquine) Indication: an antimalarial with inflammatory effect, esp in skin & joints Side-effects: Potential retinal damage retinal exam Q6 months Skin rash GI upset Steroids : Steroids Indication: potent antiinflammatory and immune suppression actions used for acute exacerbations and serious complications Side-effects: many, including GI bleed, hyperglycemia and immunocompromise Indication: steroid cream (topical) used for rash (few side-effects, except hypo-pigmentation for some creams Immunosuppressive Medications : Immunosuppressive Medications Examples: Imuran (azathioprine) and Cytoxan (cyclophosphamide): where else are they used? Immunosuppressive Medications : Immunosuppressive Medications Examples: Imuran (azathioprine) and Cytoxan (cyclophosphamide): where else are they used? Imuran (azathioprine): used for Crohn’s disease as immunosuppressive Cytoxan (cyclophosphamide): used as chemotherapy with immunosuppressive side-effects; in SLE, lower dosages are used for the immunosuppressive effects Immunosuppressive Medications : Immunosuppressive Medications Indication: suppress abnormal immune system that is creating abnormal autoantibodies and other factors that lead to inflammation and organ damage Side-effects: many, especially immunocompromise with high risk for infections; also hepatotoxicity, bone marrow suppression, pancreatitis Nursing Care for the SLE Patient : Nursing Care for the SLE Patient Lupus is characterized by fatigue. What are some steps that the pt can be taught to address the fatigue? : Lupus is characterized by fatigue. What are some steps that the pt can be taught to address the fatigue? What are some steps that the pt can be taught to address the fatigue? : What are some steps that the pt can be taught to address the fatigue? Adequate rest at night and naps is encouraged; “don’t overdo it!” Bedrest during exacerbations fatigue may be a warning Sx of impending exacerbation Plan activities and ADLs around times when pt has most energy (e.g. AM) Ask for help! With kids, housework, etc. Sit rather than stand to do activities Discuss the pt education for care of the skin and the protection of the skin from the sun. Why is protection from the sun so important for the lupus pt? : Discuss the pt education for care of the skin and the protection of the skin from the sun. Why is protection from the sun so important for the lupus pt? Why is protection from the sun so important for the lupus pt? : Why is protection from the sun so important for the lupus pt? Exposure to the sun has the potential to exacerbate lupus and aggravate symptoms Discuss the pt education for care of the skin and the protection of the skin from the sun. : Discuss the pt education for care of the skin and the protection of the skin from the sun. Protective clothing outside (long sleeves, broad brimmed hats, high collar, long trousers or skirt, socks and shoes Avoid sun in the midday (10am-2pm) Use sunscreen (high SPF) Avoid meds that sun sensitivity (tetracycline, sulfa, phenothiazines, others) Cosmetics: consult make-up professionals for products that will allow pts to go outside without embarrassment Preventive measures when the pt is at risk for infection : Preventive measures when the pt is at risk for infection Immunocompromise risk for infection Avoid large crowds Avoid situations where exposure to infection is possible, e.g. daycare Good handwashing If very neutropenic: reverse isolation (private room; masks to protect the pt, not the nurse; no flowers) The effects of pregnancy on lupus : The effects of pregnancy on lupus ½ of SLE women who are pregnant feel no change; ½ either feel better or become worse Most exacerbations occur in first trimester or in the immediate postpartum or post- abortion period Women with SLE can successfully bear children and deliver children: best if planned, during a remission, and the woman has good medical care The effects of pregnancy on lupus : The effects of pregnancy on lupus Women with serious organ disease r/t SLE (kidney, heart, CNS) should consult with MD and may be counseled against pregnancy Lupus mothers are at higher risk for toxemia and miscarriage the effects of lupus on the fertility and complications of pregnancy : the effects of lupus on the fertility and complications of pregnancy Fertility is normal when SLE is in remission Lupus is not considered hereditary There is an risk for spontaneous miscarriage, stillbirth, prematurity and low birth weight birth control measures for female pts with lupus : birth control measures for female pts with lupus Estrogen BCP: IUD (Intrauterine device): Barrier method: Birth control measures for female pts with lupus : Birth control measures for female pts with lupus Estrogen BCP: can exacerbate lupus IUD (Intrauterine device): risk for infection Irritant on uterine wall with risk for bleeding Barrier method: Best (none of the above problems) with diaphragm and condom with spermicidal jelly the signs of an acute lupus attack to teach the pt and family : the signs of an acute lupus attack to teach the pt and family severity of joint pain, swelling, fatigue, rashes, mouth ulcers, alopecia, pleuritic chest pain, shortness of breath Outline measures to promote nutrition related to fatigue, nausea and oral ulcerations : Outline measures to promote nutrition related to fatigue, nausea and oral ulcerations What are your ideas for these? Fatigue: Nausea: Oral ulcerations: Patient and Family Education (Summary) : Patient and Family Education (Summary) Education on the disease process Meds: names, actions, dosages, times, side-effects Energy conservation and pacing techniques Daily exercise and joint management Avoid triggers: physical and emotional stress, overexposure to ultraviolet light/sun, exposure to infection Patient and Family Education (Summary) : Patient and Family Education (Summary) 7. Regular medical and lab follow-up 8. Marital/fertility counseling, if needed 9. Referral to community resources and health care agencies Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Lupus: A Patient Care Guide for Nurses and Other Health Professionals Care of the Lupus Patient (sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of National Institutes of Health (NIH) lupus guide for nurses Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Systemic Lupus Erythematosus, (sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of National Institutes of Health (NIH) systemic lupus erythematosus Resources for Patient and Professional Education on Lupus : Resources for Patient and Professional Education on Lupus Nursing Diagnoses for the LE Patient : Nursing Diagnoses for the LE Patient Fatigue with Activity Intolerance Chronic or Acute Pain Body Image Disturbance Altered Sexuality (Fertility) Altered Nutrition, less than Body Requirements Ineffective management of therapeutic regimen Slide 90: How best can we deliver nursing care to this SLE pt?