MEDICAL SURGERY NUR 265 ARTHRITIS AND COMMON TISSUE DISEASES

LUPUS ERYTHEMATOSUS (DLE/SLE) PATHO  Lupus is probably caused by a complex combo of genetic and environmental factors  2 main classifications: o Discoid lupus erythematosus (DLE) – effects only the skin o Systemic lupus erythematosus (SLE) – more common  Systemic lupus erythematosus (SLE): o Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs/systems to fail o Spontaneous remissions and exacerbations o Onset may be acute or insidious (slow) o Potentially fatal, but most live many years o Autoimmune process – invades organs or deprives them of blood and oxygen o Immune complexes invade organs directly or cause vasculitis (vessel inflammation), which deprives the organs of arterial blood and oxygen. o Autoimmune complexes tend to be attracted to glomeruli of the kidneys o Often some degree of kidney involvement (lupus nephritis) – this is the leading cause of death from this disease o Onset at 20-40 years old ASSESSMENT PHYSICAL ASSESSMENT  When in remission pt. may appear fully healthy  When disease flares up, pt. may need to be admitted to the hospital  MT skin condition daily and at every home visit 1 MEDICAL SURGERY NUR 265 ARTHRITIS AND COMMON TISSUE DISEASES 265 EXAM 4 CHART 18-11 KEY FEATURES – SLE AND SSc SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) SYSTEMIC SCLEROSIS (SSc) SKIN Inflamed, red rash on face (“butterfly rash”) - can appear on other sun-exposed areas - disappears when in remission Discoid lesions - worsen when exposed to sunlight or UV light - do not disappear, but fade in remission Inflamed Fibrotic Sclerotic Edematous RENAL Nephritis Kidney failure CARIAC Pericarditis (chest pain, SOB, fever) Raynaud’s phenomenon (decreased blood flow to fingers) Myocardial fibrosis Raynaud’s phenomenon Deep vein thrombosis PULMONARY Pleural effusions (accumulation of fluid around the lungs) Pneumonia Interstitial fibrosis Pulmonary HTN NEURO CNS lupus Not common GI Abd. pain Esophagitis Ulcers GERD MUSCLE Joint inflammation (polyarthritis) Myositis Arthralgia Myositis OTHER Fever (indicates exacerbation) Fatigue Anorexia Weight loss Generalized weakness Vasculitis Osteonecrosis (bone necrosis from lack of oxygen) - most common in the hip Fever Fatigue Anorexia Vasculitis PSYCHOSOCIAL ASSESSMENT 2 265 EXAM 4  Psychosocial results can be devastating  Chronic weakness and fatigue may prevent pt. from being as active  May avoid social gatherings  Fear and anxiety from unpredictability  Limit sun exposure to prevent exacerbations LABS  Skin biopsy – confirms diagnosis o MD scraps skin cells from rash to be looked at under a microscope  Immunologic-based lab tests – same as rheumatoid arthritis  CBC – often shows pancytopenia (a decrease of all cell types)  Electrolytes  Kidney fx.  Cardiac and liver enzymes  Clotting factors INTERVENTIONS  The primary health care provider often prescribes potent drugs that are used topically and systemically  Many of the skin lesions do not disappear with treatment, but will usually fade when in remission DRUG THERAPY  DLE major concern is the rash or discoid lesions  Topical cortisone drugs – help reduce inflammation and promote fading of lesions  Tylenol or NSAIDs – treat joint and muscle pain and inflammation  Hydroxychloroquine – decreases the absorption of UV light by the skin, therefore decreasing the risk for skin lesions o Eye exams before starting drug and every 6 months while on it  Chronic steroid therapy – treats the systemic disease process  Immunosuppressive agents (methotrexate or azathioprine) – for renal of CNS lupus o Continue to take while in remission to help prevent more exacerbations  Chronic lupus = low dose steroids forever  DRUG ALERT!! – when taking steroids or immunosuppressants avoid large crowds and ill people. Report early S/S of infection to DR, take meds early in the morning before breakfast (time when the body’s natural corticosteroid level is lowest) 3 265 EXAM 4  For severe renal involvement, immunosuppressants may be given in combo with steroids  New drugs: o Lupozor o Belimumab (Benlysta)  Increases risk for infection  Do not receive live viruses for 30 days before tx. PROTECTING THE SKIN  PROTECT SKIN TO PREVENT AN EXACERBATION  ACTION ALERT!! – Avoid prolonged exposure to sunlight and other forms of UV light, wear long sleeves and large-brimmed hat when outdoors, use sunblock SPF 30 or higher.  CHART 18-12 SKIN PROTECTION FOR LUPUS ERYTHEMATOSUS o Wash with mild soap (Ivory) and dry skin thoroughly by patting NOT rubbing. o Avoid harsh perfumed substances o Cosmetics should include moisturizers and sun protectant o Use lotions o Avoid powders, rubbing alcohol, and drying agents. o Use gentle shampoos and avoid harsh hair treatments (Alopecia/hair loss is common) o Avoid direct sunlight and ultraviolet light including tanning beds o Wear long sleeves, wide-brimmed hats, long pants when in the sun o Use sunscreen – SPF 30 or higher o Inspect skin daily for rashes and lesions. CARE MANAGEMENT  2 major differences exist between SLE and rheumatoid arthritis (RA) in terms of education of the pt. and family o 1. SLE – how to protect the skin o 2. SLE – MT body temp. (fever is a major S/S of exacerbation)  Teach the importance of reporting any other unusual or new S/S to the primary MD immediately.  Identify coping strategies and support systems for the unpredictability of this condition – fear and anxiety  Pregnancy can be a stressor that causes an exacerbation (during and after birth) o Increased risk for stillbirth, miscarriage, and premature birth 4 265 EXAM 4 o Pregnancy not recommended for those with renal, cardiac, and CNS involvement