hey everyone it's sarah register nurse rn.com and in this review i'm going to talk about systemic lupus erythematosus and as always whenever you get done watching this youtube video you can access the free quiz that will test you on this content so let's get started systemic lupus erythematosus also known as lupus or sle is an autoimmune condition that causes inflammation that targets organs tissues and joints and this inflammation can actually be so severe that it can permanently damage these structures now where are these autoimmune attacks occurring where is the body actually turning on itself and causing this severe inflammation well it tends to affect these structures right here and it varies among patients some patients will have these areas affected while others may have these areas affected but you can look at the patient's signs and symptoms and that may give you clues about which area of the body is being affected by lupus and how they're affected can be mild to severe so the joints can be affected along with the skin the lungs the heart kidneys brain and blood system now let's go over some key points about lupus that i want you to keep in mind as i go through this lecture so with lupus this is a chronic condition and patients will experience flare-ups where they have signs and symptoms presenting to periods of remission where they are signed and symptom-free which makes it a little bit difficult to diagnose so it takes a lot of investigative work by the physician in that the physician has to look at the patient's family history along with the patient's health history their presenting signs and symptoms and certain laboratory results to actually diagnose this condition and this condition currently does not have a cure but there are many treatments available to actually help improve the patient's quality of life decrease their episodes of flare-ups and help maintain remission furthermore there are different types of lupus with sle being the most common form it tends to affect women more than men specifically black latina and asian women who are in their childbearing years therefore they think that hormones may play a role with the onset of this chronic disease due to the fact that it starts whenever menstruation begins and it gets worse during pregnancy and during that postpartum period therefore it's very important you provide education to that woman who desires to have children also other risk factors is a genetic factor so a family history along with environmental causes like too much sun exposure or exposure to a certain infectious disease or medications now let's talk about the pathophysiology for how lupus is occurring in the body well it all starts with a cell and we're specifically talking about how the cell undergoes death so how the cell is supposed to die and a fancy term for this whole process is called apoptosis so let's take a closer look at the structure of the cell the cell consists of many parts it has a cell wall on the outside and on the inside it has many important structures with one of these structures being the nucleus the nucleus stores chromosomes with our dna and plays an important role with synthesis of proteins and ribosomes now our body expects our cells to be healthy and if our cells become unhealthy they know it's time to die because if they decide to stick around they can become cancerous and they can grow and multiply and eventually kill us so the cell sacrifices itself for the greater good of all the other cells and it undergoes apoptosis it knows it has to die and again it has to go through this process very specifically so the cell what it's going to do whenever it's unhappy as our cell is up here it's going to shrink down in size and that outer membrane is going to start to lose its integrity and bleb out and then the inside material is going to start to break down like the nucleus and other things now during this whole process it's sending out like a chemical signal to other members of the immune system such as the macrophages the role of the macrophage is to come and ingest and engulf things that need to be cleaned up that's its job so once they start to arrive what's going to happen to this cell is it's going to start to shatter into these tiny pieces called apoptotic bodies and this macrophage what it's going to do it's going to go and eat those bodies right up and then our process is complete it's done with now the problem they think with lupus is this phagocytosis is ineffective either this macrophage is taking too long to consume these apoptotic bodies or they're not really consuming them at all so these tiny fragmented pieces which have parts of our cell in it are hanging out in the body and they can't do that too long until they start to leak so they leak and spill their contents inside the body well we have an immune system that's constantly on alert on surveillance so whenever it sees the leakage of this material from these apoptotic bodies it's like uh oh we have nuclear antigens foreign invaders so the immune system goes and forms anti-nuclear antibodies and i want you to remember that because there's a test for lupus where we're going to test them for an ana and it'll be positive in lupus so that's where that's coming from so once these antibodies are formed it attacks these antigens we get an immune complex there in our body this immune complex is going to float around in the body and it can go and collect in these systems of the body so once these immune system complexes are in these structures the body's like hey what is this we don't like this we need some more inflammation so we can get rid of these things so what it does is it helps activate the complement cascade that system helps promote hence complement our immune system so you get proteins that help with this like c3 and c4 and we get some inflammation there now they the body thinks it's helping because it's attacking this immune complex but in reality it's really attacking our own cells specifically the material inside our cells so if this inflammation is severe enough and it keeps happening over and over it will eventually permanently damage these structures now let's talk about the signs and symptoms of lupus what could you expect to see in a patient who has lupus as the nurse well again remember it's going to vary among patients because it depends on where these immune complexes have decided to congregate and cause that inflammation so we're going to start from head to toe first let's look at the eyes lupus can affect the eyes causing them to become inflamed so they'll present as dry and red and the mouth can be affected where the patient has the development of ulcers can also affect the brain hence the mental part of your patient a lot of patients a big sign and symptom is fatigue they feel extremely tired they can also have memory loss they can have psychosis they can even have seizures and a lot of them will start to have fevers as well also the skin and hair can be affected they will have photosensitivity meaning the sunlight can actually activate or trigger their signs and symptoms hence cause a flare so they can have rashes on the skin one rash is known as the butterfly rash the proper term for that is malar rash they can also have a rash called a discoid rash and discoid means disc shape so they're round and they tend to be on areas of the skin that are exposed to sun in addition patients can have alopecia where they actually lose their hair the heart can also be affected and this is where you're having this inflammation on this heart muscle it can weaken the muscle causing heart failure the patient can also feel chest pain where it's affecting the lining that surrounds the heart causing pericarditis and even the valves inside the heart that open and close which allow blood to flow through the lining of that can become inflamed so you can hear heart murmurs in addition some patients can have lung issues where that outside lining that surrounds the lungs becomes inflamed so they can have chest pain with that also they can develop infections like pneumonia or pleuratus the kidneys can also become affected where they just become really inflamed and some patients can experience what's called lupus nephritis and this is where that functional unit of the kidneys called the nephrons this is where all of your filtering of the blood takes place with electrolytes waste etc can become affected so you can start to see protein in the urine which will lead the patient to start to retain fluid they can also start to have an elevated blood pressure hypertension from where there's so much more fluid in the blood and the patient may need dialysis or a transplant so it can lead to renal failure in addition the blood system can be affected and we can have immune complexes and there's a risk for infection with patients with lupus and this can be from treatment suppressing the immune system and just the inability to effectively clear those foreign invaders due to ineffectiveness of the phagocytosis and removing those invaders so it's important that the patient stays up to date with their vaccines but they want to avoid those live vaccines because treatments again further complicate their immune system suppressing it and just how the disease process is in itself it can increase their risk of developing an infection also blood clots can develop and patients can actually develop a condition called anti-phospholipid syndrome and this is where the immune system is causing the body to clot more so blood clots can occur due to antibodies against blood cells platelets red blood cells and the white blood cells can also be affected and this is where you can start to see anemia the joints and muscles can also be affected a lot of patients will talk about how they have swollen joints they will be very painful and it'll be like arthritis type pain in addition they can start to have something called renaud's syndrome where they will have bluish or pale fingers and toes whenever they're exposed to cold and in women who are in child bearing years the uterus can be affected because there is an increased risk of clotting so flare-ups can happen leading to blood clotting during pregnancy and during the postpartum period due to the fluctuation of hormones so it's important that the patient if they want to get pregnant plans it in advance and most patients need to have their disease in remission for at least six months in order to prevent a flare during pregnancy now let's talk about the nurses role for a patient who has lupus how do we care for them well we've already learned that lupus can affect any system of the body so our care really needs to be tailored to whatever system is being affected by lupus and it can really vary among patients so one complication that can happen is like lupus nephritis and we know nephritis means kidney inflammation so our nursing care really needs to be focusing on those kidneys how can we do that well more than likely the physician is going to order some labs to monitor kidney function and it's our job to look at those labs and report abnormalities so we can look at the bun and creatinine this will be elevated if we're having renal insufficiency also you can check the urine for protein because there should not be protein in the urine that tells us the nephrons of our kidneys are slipping up in that they're allowing protein to go into the kidneys and the patients urinating that out so they'll have protein urea also we need to look at the patient's urinary output collecting that urine every time they void and measuring that out because we want to make sure they're at least putting out 30 cc's per hour in a 24-hour period also we can weigh them put them on a scale and measure that daily are they retaining fluid if they are if they're elevating in their weights that tells us they are gaining weight that means they're probably keeping fluid because kidneys help us maintain our fluid balance so you want to look for signs of heart failure like pulmonary edema or swelling in those lower legs is your patient having shortening shortness of breath etc but let's say our patients having joint issues because of their lupus well we want to help them manage that joint pain with medications that are ordered by the physician in addition we want to preserve their joint mobility by helping them use techniques that do that maybe consulting physical therapy to help the patient and educating them about the importance of exercise to maintain joint stability now the nurse also plays a huge role with educating so we're going to educate the patient about this whole disease process help them get a better understanding because whenever patients understand their disease they can understand how to take care of themselves better also teach them about medications because medications are going to be a big vehicle used to treat a patient with lupus because it helps them manage their disease also we want to teach a lot of these patients because again women who are in their childbearing years about pregnancy and how they can deal with their lupus if they're wanting to have a child so to help guide us with all those main concepts in this review we're going to remember the word lupus so l is for labs to help diagnose and monitor flares as a nurse we want to be really familiar with what labs can be ordered by the physician to help determine if a patient may have lupus so first antibody labs that can be ordered a patient who potentially has lupus may have a positive ana this is an antinuclear antibodies and this demonstrates there are auto antibodies the body has created against the nuclei of the cells and we talked about how they spilled out and the body's like hey we're going to attack you so it created antibodies and these are nuclear antibodies that can also be present with other autoimmune disorders so we need to order some other labs to help further evaluate this another lab that can be ordered is an anti-double stranded dna antibody and this is a particular antinuclear antibody found in some patients with lupus and is not typically present in patients who don't have lupus in addition an anti-smith antibody can be ordered and this is just another particular antibody found in the nucleus that correlates with lupus other tests that can be ordered are like an esrp which is an erythrocyte sedimentation rate and a c-reactive protein crp and what these labs are they will be elevated and they help monitor inflammation in the body so anything that's really causing inflammation can cause this but we know that whenever patients have flare-ups they have inflammation so it can be helpful with detecting lupus flares and how treatment is working in addition a compliment test can be ordered and this is where they can look at those proteins and that complement cascade that i was talking about where it helps complement hints promote inflammation in the body and we start inflaming all those structures and you can look at those proteins c3 and c4 and there will be a low count of them now why is it low well because they're out fighting this foreign invader causing inflammation so we're depleting the body of them so this assesses if inflammation is occurring and if these proteins are being used in this inflammation process and also a complete blood count can be ordered where we can look at other cells like look for white blood cells like to see if anemia is being caused or looked at metabolic panel which can help us determine renal function then you for use medications so medications can help decrease occurrence of flares it can protect organs tissues and joints from damage and it can help improve the quality of life for a patient who has lupus one group of drugs used to treat lupus or steroids and some examples of these drugs are like prednisone or pregnissalone and this helps decrease inflammation and it does it relatively quickly so the patient gets quick results which is very helpful whenever they're going through some severe joint pain or some severe pain with breathing or their skin so steroids typically are used for severe cases and they're not for long-term usage and they have to be tapered off and this is because they can cause some really bad side effects like weight gain they can cause diabetes increasing their blood sugar they can decrease bone health leading to osteoporosis and they increase a patient's risk for infection nsaids are also used and these are known as non-steroidal anti-inflammatory drugs and this includes drugs like ibuprofen or naproxen now they help decrease inflammation so they're helpful for patients who are suffering from fever joint pain etc however with these drugs they have gi issues there's a risk for developing ulcers and bleeding so you want to educate the patient to take them with food and you'll want to monitor the kidney function because they can affect the kidneys as well anti-malarial drugs can be used and this includes a medication called hydroxychloroquine and this decreases antibodies attacking the body so it's useful in controlling the disease long term hence preventing those flares so some things you want to educate the patient about is that they're not going to see immediate results it can take a couple months to start seeing this medication take effect in the body they also want to take it with food because this can this medication can cause gi problems so that can help decrease it and whenever they're taking this long term they have to get their eyes checked regularly a minimum of yearly sometimes twice a year because this medication group can actually damage the retina of the eye and if a patient smokes they want to quit smoking because it actually makes the drug less effective also immunosuppressants can be used and this includes drugs like azathioprine or mycophenolate mophile and these suppress the immune system just as their name says so they are used in severe cases of lupus and you may hear them referred to as steroid sparing and this means the use of them helps lower the amount of steroids the patient may have to take because we want to limit steroids in a patient because of all those side effects associated with them now these medications the patient needs to be educated that it increases the risk of infection so it's very important that the patient helps prevent infection you know keeping their vaccines up to date and monitoring themselves for infection because a medication regimen for lupus they may be taking this along with some steroids that can prevent the symptoms of infection appearing like fever so with vaccines as i said it's important to stay up to date but they want to watch the live vaccines none of those because it could lead to an infection and some live vaccines include the shingles vaccine mmr the intranasal flu vaccine smallpox rotavirus and then lastly we have the biologics and this can include bulimimab and what this medication does is it binds with a protein that supports the activity of b cells and this will help decrease the activity of b cells hence we're going to get a decrease in antibody attacks and decrease inflammation now this is usually prescribed with other lupus medications and you want to educate the patient that it takes time to start experiencing relief it can take up to six months half a year and it's given via infusion or injection so if the patient does give this to themselves you want to educate them how to do that properly it goes in the subcutaneous fat they can use the thighs or the abdomen's fat and as the nurse you want to assess the patient's mental health because with this medication there is a risk for them developing depression or even suicidal thoughts so watch out for the warning signs like with depression is the patient having trouble sleeping loss of appetite they've had a loss of interest in things they used to like doing they have sadness that they just can't shake those could all be warning signs and they need to monitor themselves for infection because they are at risk for that and again no live vaccines while taking this medication then p is for pregnancy so again as i said at the beginning of the lecture most patients with sle are going to be women and they tend to be within child bearing age so you want to educate them about their lupus needing to be in control no flare-ups for at least six months before trying to conceive because there's the increased risk of miscarriage and then plus pregnancy in the postpartum period can cause flares u is for understanding flares so as a nurse you want to be familiar with things that can trigger a lupus flare and educate the patient about it so sunlight can do this along with stress this could be emotional stress physical stress even illness surgery and that goes along with the next point sickness and then medications maybe they don't have enough medications on board or they've just changed medications or they haven't been taking their medications that can lead into a flare so as a nurse you want to take time to educate your patient on how they can prevent a flare of lupus so to help us remember those key points let's remember the word less because we want less flares so l is for lower stress so help the patient identify areas where they're over working or areas that cause them emotional stress physical stress or even illness and to use some relaxation techniques to help keep their stress level low e is for exercise exercise is really important for a patient who has lupus it's going to help manage their weight but it's also going to help with joint mobility and then s is for sleep a patient with lupus needs more sleep than people who don't have lupus so they need more than eight hours because they need their body to rest and not get exhausted because if their body gets exhausted goes back to the first cell it causes stress on the body and they can have issues and then the last s is for sun protection as we pointed out in the signs and symptoms sunlight can actually activate a flare so it's really important that these patients use sunscreen and they wear large brim hats to keep the sun off their face especially since they're at risk for the butterfly rash and to wear long sleeves and then the last part of our lupus pneumonic is signs of a flare so you want to educate the patient to really keep track of their symptoms and write them down because certain signs and symptoms start to present early on before the disease becomes active so to help us remember those signs of flare let's remember the word flare f is for fatigue l is for low grade fever a is for achy joints r is for rashes and then e is for edema swelling in the legs and the hands okay so that wraps up this review over systemic lupus erythematosus and don't forget to access the free quiz that will test you on this content