4.6 Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect various different organs and tissues in the body. It is characterized by the immune system mistakenly attacking healthy cells and tissues, leading to inflammation and damage. SLE is known for its diverse and fluctuating symptoms, which can range from mild to severe and can affect nearly any part of the body.

In SLE, the immune system loses its ability to differentiate between foreign substances (like viruses or bacteria) and the body’s healthy tissues. This leads to the production of autoantibodies that attack the body’s own cells and tissues. SLE often follows a pattern of flare-ups (periods of increased disease activity with symptoms) and remissions (periods of reduced or absent symptoms). Exacerbation can be triggered by stress, infections, sunlight exposure, or certain medications.

Various demographic factors elevate the risk of SLE. Women, particularly those between the ages of 15 and 40, are susceptible to SLE. Additionally, individuals of African American, Asian, or Native American descent exhibit a higher prevalence and increased risk for SLE.^[1]

The symptoms of SLE vary widely from person to person. They can range from mild to severe, and they may come and go. Common symptoms can include arthritis, fatigue, and a classic rash that appears on the face across the nose and cheeks called a “butterfly rash.”^[2] See Figure 4.15^[3] for an image of a butterfly rash associated with lupus.

Assessment

Signs and symptoms of SLE may be found across various body systems and can fluctuate. See Table 4.6 for a summary of potential manifestations of SLE across body systems.

Table 4.6. Potential Manifestations of SLE Across Body Systems^[4],[5],[6]

Diagnostic Testing

There are no specific tests to diagnose lupus. Health care providers use several criteria to support the diagnosis. Diagnostic testing for SLE may include the following laboratory tests^[7],[8]:

• Antinuclear Antibody (ANA): Detects the presence of antibodies that attack the body’s own cells.
• Complement Levels (C3 & C4): Measures complement proteins that are suppressed in SLE.
• Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP): These tests identify signs of inflammatory processes within the body.
• Skin Biopsy: A skin biopsy may be performed when skin manifestations are present.

Nursing Diagnoses

Nursing diagnoses encompass a range of physical, emotional, and lifestyle-related challenges. Common nursing diagnoses for individuals with SLE include the following:

• Chronic Pain
• Fatigue
• Risk for Impaired Skin Integrity
• Disturbed Body Image

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Sample expected outcomes for a client diagnosed with SLE are as follows: 

• The client will verbalize three nonpharmacological pain management techniques by the end of the teaching session.
• The client will report improved energy levels within one week of medication therapy. 
• The client will verbalize two skin care techniques to prevent skin breakdown by the end of the teaching session.
• The client will verbalize feelings related to body image changes within two weeks.

Interventions

Medical Interventions

Medical interventions for SLE focus on medication therapy.

Medication Therapy

Medication therapy aims to reduce symptoms and flare-ups with a variety of classes of medication^[9],[10]:

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDS (i.e., ibuprofen and naproxen) reduce inflammation, alleviate mild joint pain, and manage musculoskeletal symptoms.
• Corticosteroids: Corticosteroids like prednisone reduce inflammation in severe or organ-threatening manifestations of SLE.
• Immunosuppressant Agents: Medications like azathioprine, methotrexate, and mycophenolate mofetil may be prescribed to suppress the immune system and control disease activity in individuals experiencing severe symptoms who are not responding to other medications.
• Antimalarials: Antimalarial medications like hydroxychloroquine and chloroquine may be prescribed for their anti-inflammatory properties to manage joint pain, skin rashes, and fatigue and to prevent flare-ups.
• Biological Response Modifiers: Biological response modifiers like belimumab and rituximab target specific components of the immune system to control inflammation and reduce disease activity.
• Calcineurin Inhibitors: Calcineurin inhibitors like tacrolimus or cyclosporine may be prescribed in certain cases to suppress the immune response.

Nursing Interventions

Health Teaching

Nurses educate clients about SLE, its potential complications, and the importance of adhering to treatment plans. Information on lifestyle modifications is provided, including sun protection, balanced nutrition, and exercise. Clients receiving immunosuppressant medications are taught about the importance of good hand hygiene and avoiding individuals with infections to reduce the risk of complications.

Psychosocial Support

Nurses actively listen and provide therapeutic communication to encourage a client’s open communication about the emotional impact of living with a chronic illness. Nurses facilitate access to support groups or counseling services to promote effective coping strategies.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.