In this article, we go in depth on the autoimmune disease lupus, including its pathophysiology, risk factors, signs and symptoms, how to diagnose lupus, lupus treatments, and nursing care and patient teaching. Lupus is almost always featured on Med-Surg exams that cover the immune system, so it’s important to know! This disease is covered in our Medical-Surgical flashcards (Immune system), and Cathy’s video follows along with the cards.
Medical-Surgical Nursing - Flashcards
What is systemic lupus erythematosus (SLE)?
Systemic lupus erythematosus (SLE or just “lupus’) is a chronic inflammatory disorder in which the body’s immune system attacks the body’s own organs and connective tissues, causing widespread inflammation and tissue damage. It should not be confused with discoid lupus, which primarily affects the skin.
Pathophysiology of SLE
Lupus is an autoimmune disorder that results in the production of antinuclear antibodies (ANA), which causes inflammation and damage to the body's organs, including skin, lungs, kidneys and heart.
Lupus, like other autoimmune disorders, is marked by periods of exacerbations (flare ups) and periods of remission.
Risk factors for SLE
Women are much more likely than men to get lupus. Onset of lupus usually occurs between the age of 20 and 40.
Patients who are Black, Asian, or Native American are statistically at a higher risk for lupus. It is important to note the word statistically. Race does not play a biologically predetermined role in this disease, but the risks and severity of complications are higher statistically for communities of color for a variety of reasons, including the social and environmental determinants of health — financial resources; access to adequate and nondiscriminatory health care; and more.
Signs and symptoms
The most common signs and symptoms of systemic lupus include fatigue, joint pain, fever, a butterfly rash across the face, and Raynaud’s syndrome. Other symptoms include anemia, pericarditis (inflammation of the membrane that surrounds the heart, and enlarged lymph nodes
Raynaud’s syndrome
Raynaud’s syndrome causes the extremities, mostly fingers, to become pale, cold and numb due to vasospasming, which is decreased blood flow.
Diagnosis & associated lab values
Patients can be diagnosed with lupus using several diagnostics, including the ANA titer, serum complement (C3 and C4), BUN and creatinine with kidney involvement, and RBC, WBC, and platelet counts. These lab values are important to know for your Med-Surg exams and can be found in our Lab Values flashcards for easy studying.
White blood cells (WBC)
White blood cells are a key component in the body’s immune system for fighting infection and disease. The expected range for white blood cells is 5,000 - 10,000/mm³. Patients with lupus will have decreased white blood cell counts. In our video on the immune system diagnostic tests, we cover the five different types of white blood cells.
Red blood cells (RBC)
Red blood cells are the circulating cells that transport oxygen to the body’s cells. The expected range for women is 4.2 - 5.4 million/uL and for men it’s 4.7 - 6.1 million/uL. Patients with lupus will have decreased red blood cell counts.
Platelets
Platelets are blood cell fragments used to form clots in the body, to stop bleeding. The expected range for platelets is 150,000 - 400,000 mm³. Patients with lupus will have decreased platelet counts, and decreased platelet counts create a high risk of bleeding!
Creatinine
Creatinine is the waste product from the normal breakdown of muscles in the body. The expected range of creatinine is 0.6 - 1.2 mg/dL. If a patient’s kidneys have been damaged by lupus, their creatinine levels would be increased, reflecting the presence of kidney dysfunction. It is considered a more accurate assessment of kidney function than BUN.
Blood Urea Nitrogen (BUN)
BUN is the nitrogen in the blood from the waste product urea (produced when protein is broken down in the body). The expected range for BUN is 10 - 20 mg/dL. If a patient’s kidneys have been damaged by lupus, their BUN levels would be increased. BUN is considered a less accurate measure of kidney function than creatinine because it can also be increased due to dehydration.
Treatment for lupus
There are multiple medication options available for treating lupus and the symptoms associated with it, including NSAIDs, immunosuppressants, and hydroxychloroquine. In addition to these medications, the provider may prescribe a topical steroid cream for the rash on the face.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs like ibuprofen, or aspirin, can be used to reduce the pain, inflammation, and stiffness seen with lupus. These medications might seem basic, but some important side effects to know with these medications are GI bleeding and renal toxicity. Renal toxicity is especially important to consider as some lupus patients may already have kidney dysfunction.
Immunosuppressants
Immunosuppressant medications suppress the effects of the immune system. These types of medications were originally created for organ transplant recipients, so that their immune system would not see the new organ as “foreign” and attack it. Because autoimmune disorders like lupus and rheumatoid arthritis are caused by the immune system attacking itself, taking immunosuppressants for these conditions can have similarly beneficial effects.
Medications that fall in the immunosuppressant class are prednisone and methotrexate. These medications are ones you’ll need to know for your Pharmacology courses and are covered in our Pharmacology Flashcards that we created to make memorization easy!
One important side effect to know with immunosuppressants is that they place the patient at a much higher risk of developing an infection. Patients should notify their provider right away if they notice any signs of infection.
Methotrexate is a category X drug for pregnancy, which means it should NOT be taken by pregnant patients. All patients on long-term methotrexate therapy must also be on some form of contraception.
Hydroxychloroquine
Hydroxychloroquine is an effective medication for lupus because in addition to its main mode of action (inhibiting protein synthesis) it acts to suppress the cytokines (cellular messengers), effectively suppressing the immune system and reducing inflammation.
Hydroxychloroquine was originally created to treat and prevent malaria. Interestingly, it was developed based on the chemical structure of quinine. Quinine is also an antimalarial but is the main ingredient in tonic water -- and gin and tonics were originally popularized to ward off malaria (though the tonic water of today contains much less quinine).
Nursing care & patient teaching
Nursing care for lupus will include providing the above medications as needed, and monitoring for complications including renal failure. You will also need to provide some important teaching to your patient, including:
- They should avoid sun exposure and wear sunscreen to prevent skin damage, as their skin is more susceptible to burns.
- It’s important for this patient to prevent infection because their immune system is less able to fight off foreign invaders, and if they are taking immunosuppressants, this is doubly true. They should avoid sick people and protect themselves from getting infections.
- This patient should take frequent rest periods because of the side effects of fatigue associated with lupus.
If you need an easy way to memorize WBCs, ESR, and CRP levels, check out ourLab Values Flashcards. Cathy’s teaching on the immune system is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.