Med-Surg Immune System, part 5: Systemic Lupus Erythematosus

by Cathy Parkes September 30, 2020

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.

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 aspirin or ibuprofen 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.


Full Transcript

Alright, in this video, I'm going to talk about systemic lupus erythematosus, or SLE. So if you're following along with cards, I'm on card number 12.

SLE is a chronic inflammatory disorder of the connective tissue and it causes widespread inflammation as well as tissue damage.

Now, keep in mind as I go through this information, I'm talking about systemic lupus and not discoid lupus, which primarily just affects the skin.

So in terms of the pathophysiology behind this disorder, systemic lupus is an autoimmune disorder which results in the production of antinuclear antibodies, or ANA. And this results in inflammation and damage to many organs in the body, including the skin, the lungs, the kidneys, and the heart.

And just like other autoimmune disorders, lupus is characterized by periods of exacerbations as well as periods of remission.

In terms of the risk factors, women are much more likely to get lupus. Onset of the disease usually occurs between the ages of 20 and 40. And race also plays a role, so African Americans, Asians, and Native Americans are at higher risk for getting lupus.

Signs and symptoms of systemic lupus include fatigue, joint pain, fever, a butterfly rash across the face. So that's one of the hallmark symptoms of this disorder, as well as Raynaud's phenomenon. So with Raynaud's, you have vasospasming, so decreased blood flow to the extremities, to the fingers. So those fingers become pale, numb, and cold. So if you Google Raynaud's, you'll see lots of pictures of pale fingers and you can imagine that they're probably numb and cold, too.

Other symptoms include anemia, pericarditis, which is inflammation of the membrane that surrounds the heart, as well as lymphadenopathy, so enlarged lymph nodes.

In terms of the labs and how we would diagnose this condition, patients who have lupus will usually have a positive ANA titer.

And they will also have decreased serum complement, so decreased C3 and C4.

In addition, they'll have decreased red blood cells, white blood cells, and platelet counts.

And then, if their kidneys become involved at some point, then we would see an increase in BUN and creatinine as well.

In terms of treatment, NSAIDs can be used but we also usually provide immunosuppressants to patients with lupus because it is an autoimmune disorder and we're trying to suppress that immune system.

Medications that fall within this class include prednisone as well as methotrexate.

Hydroxychloroquine is also an effective medication for lupus. So hydroxychloroquine is actually a medication used for malaria but it is also used for autoimmune disorders such as lupus.

And then, the provider may also prescribe a topical steroid cream for the rash on the face, for that butterfly rash.

In terms of nursing care, in addition to providing these medications, you're going to really monitor for complications, including renal failure.

And then you're going to provide some important teaching to your patient.

So some of those key teaching points include avoiding UV and sun exposure to prevent skin damage.

Also, the patient needs to really prevent infection, so they should avoid sick people and really protect themselves from getting infection.

And then they need to take frequent rest periods as well because of that side effect of fatigue associated with systemic lupus.

Okay, so that's it for lupus. When I come back on my next video, we will talk about scleroderma. Thank you so much for watching!


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