Nursing Care Plans

4 Systemic Lupus Erythematosus Nursing Care Plans

August 8, 2017

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that causes a systemic inflammatory response in various parts of the body. The cause of SLE is unknown, but genetics and hormonal and environmental factors are involved. Under normal circumstances, the body’s immune system produces antibodies against invading disease antigens to protect itself. In individuals with SLE, the body loses its ability to discriminate between antigens and its own cells and tissues. It produces antibodies against itself, called autoantibodies, and these antibodies react with the antigens and result in the development of immune complexes. Immune complexes proliferate in the tissues of the client with SLE and result in inflammation, tissue damage, and pain. Mild disease can affect joints and skin. More severe disease can affect kidneys, heart, lung, blood vessels, central nervous system, joints, and skin.

There are three types of lupus. The discoid type is limited to the skin and only rarely involves other organs. Systemic lupus is more common and usually more severe than discoid; it can affect any organ system in the body. With systemic lupus, there may be periods of remission and flares. The third type of lupus is drug induced. The drugs most commonly implicated in precipitating this condition are hydralazine (Apresoline), procainamide (Pronestyl), isoniazid (INH), chlorpromazine (Thorazine), d-penicillamine, and some anti-seizure medications. Symptoms usually do not present until after months or years of continued administration. The symptoms are usually abolished when the drugs are discontinued.

Nursing Care Plans

Nursing goals of a client will systemic lupus erythematosus (SLE) may include relief of pain and discomfort, relief of fatigue, maintenance of skin integrity, compliance with the prescribed medications, and increased knowledge regarding the disease, and absence of complications.

Here are 4 nursing diagnosis and nursing care plans (NCP) for Systemic Lupus Erythematosus (SLE):

Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.

May be related to

Exacerbation of disease process
High-dose corticosteroid use
Inflammation
Use of immunosuppressant drugs
Vasoconstriction

Possibly evidenced by

Diffuse areas of hair loss
Itching
Loss of discrete patches of scalp hair
Oral and nasal ulcer
Pain and tenderness
Redness
Scalp hair loss possibly accompanied by lesions, scarring, or dry, scaling skin tissue
Skin breakdown
Skin rash

Desired Outcomes

Client will verbalize ability to cope with hair loss.
Client will identify measures to cover scalp loss as required by personal preference.
Client will maintain optimal skin integrity, as evidenced by an absence of rashes and skin lesions.

Nursing Interventions	Rationale
Assess the skin for integrity.	Small lesions may develop on the oral and nasal mucous membranes. Disclike lesions that appear as a dense maculopapular rash may occur on the client’s face or chest.
Assess the client’s description of pain.	Gathering information about pain can guide treatment. Each client may exhibit slightly different presentations.
Assess for an erythematous rash, which may be present on the face, neck, or extremities.	The classic “butterfly” rash may appear across the bridge of the nose and on the cheeks and is characteristically displayed in the configuration of a butterfly. This is evident in about 50% of clients.
Assess for photosensitivity.	Clients may respond violently to ultraviolet light or to sunlight. Disease flares or outbreaks of severe rash may occur in response to exposure.
Assess the degree to which symptoms interfere with the client’s lifestyle and body image.	A broad range of behaviors is associated with body image changes, ranging from totally ignoring the change to a preoccupation with it.
Encourage adequate nutrition and hydration.	These measures promote healthy skin and healing in the presence of wounds.
Instruct the client to clean, dry, and moisturize intact skin; use warm (not hot) water, especially over bony prominences; use unscented lotion. Use a mild shampoo.	Scented lotions may contain alcohol, which dries the skin. Prescribed solutions reduce dryness of the scalp and maintain skin integrity.
Instruct the client to avoid contact with harsh chemicals and to wear appropriate protective gloves, as needed. Avoid hair dye, permanent solution, and curl relaxers.	Chemicals aggravate this condition.
Recommended prophylactic pressure-relieving devices (e.g., special mattress, elbow pads).	Such devices aid in the prevention of skin breakdown.
*For skin rash:*
Wear protective eyewear. Wear a wide-brimmed hat and carry an umbrella. Wear maximum protection sunscreen (SPF 15 or above) in the sun. Sunbathing is contraindicated. Avoid ultraviolet ray.	The sun can exacerbate a skin rash or precipitate a disease flare. Special lotions, glasses, and other items may be required to protect the skin from sunlight exposure.
Inform the client of the availability of special makeup (at large department stores) to cover rashes, especially facial rashes.	These preparations are specially formulated to completely cover rashes, birthmarks, and darkly pigmented areas. This will help the client who is having problems adjusting to body image changes.
Introduce or reinforce information about the use of hydroxychloroquine.	This antimalarial drug is a slow-acting medicine used to relieve or reduce inflammation and rash. It may take 8 to 12 weeks for effect. A potential side effect is retinal toxicity. The client must follow up with an ophthalmologist every 6 months. Topical cortisone medication may likewise be used.
For oral ulcers:
Instruct the client to avoid spicy or citrusy foods.	These foods might irritate fissures or ulcers in the mucous membranes.
Instruct the client to rinse the mouth with half-strength hydrogen peroxide three times per day.	Hydrogen peroxide helps keep oral ulcers clean.
Instruct the client to keep ulcerated skin clean and dry. Apply dressings as needed.	Skin is necessary to prevent infection and promote healing.
Instruct the client to apply topical ointments as prescribed.	Vitamin A and E may be useful in maintaining skin health.
For hair loss:
Instruct the client that scalp hair loss occurs during exacerbation of disease activity.	Scalp hair loss may be the first sign of impending disease exacerbation. Scalp hair loss may not be permanent. As disease activity subsides, scalp hair begins to regrow.
Instruct the client that scalp hair loss may be caused by high-dose corticosteroids (prednisone) and immunosuppressant drugs.	Hair will regrow as the dose decreases.
Encourage the client to investigate ways (e.g., scarves, hats, wigs) to conceal hair loss.	Hair loss may interfere with lifestyle and self-image.

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

Inflammation associated with increased disease activity

Possibly evidenced by

Facial grimace
Guarding on motion of affected joints
Moaning or other pain-associated sounds
Verbalized complaint of joit pain or stiffness

Desired Outcomes

Client will report pain or stiffness at a level less than 3 to 4 on a scale of 0 to 10.
Client will implement a pain management plan that includes pharmacological and nonpharmacological measures.
Client will be able to participate in self-care activities.

Nursing Interventions	Rationale
Assess the client’s description of pain.	Clients with SLE often experience arthralgias of many joints with morning stiffness. Joint stiffness related to systemic lupus erythematosus (SLE) may not be related to activity or overuse; it is instead a response to immune complexes proliferating and setting up an inflammatory response in that particular body part. Clients with SLE may also have arthritis; thus stiffness and discomfort are multifactorial.
Assess the impact of pain or stiffness on the client’s ability to perform interpersonally, socially, and professionally.	SLE-related arthritis usually does not result in deformity as in rheumatoid arthritis, but physical activity may still be severely limited at times. Strategies may have to be developed so that the client is able to maintain a maximum level of function in each of these areas.
Assess for the signs of joint inflammation (warmth, redness, swelling) or decreased motion.	Usual signs of inflammation may not be present with this disease.
Assess previous measures used to alleviate pain.	Clients may not know of or may not have tried all currently available treatments. Pain management is directed at the resolution of discomfort as it is presenting at that specific moment in time, because relief measures may change with the affected joints.
Encourage the use of ambulation aids when pain is related to weight-bearing.	Crutches, walkers, and canes can be used to absorb some of the weight from the inflamed extremity.
Encourage the client to assume an anatomically correct position with all joints. Suggest that the client uses a small flat pillow under the head and not use a knee gatch or pillow to prop the knee.	Such measures assist in preventing the development of contractures.
Remind the client to avoid prolonged periods of inactivity.	Activity is required to prevent further stiffness and to prevent joints from freezing and muscles from becoming atrophied.
Encourage the client to perform range-of-motion (ROM) exercises after the shower or bath, two repetitions per joint.	These exercises help reduce stiffness and maintain joint mobility.
Remind the client to allow sufficient time for all activities.	Performing even simple activities in the presence of significant joint stiffness can take longer.
Encourage the client to take a 15-minute warm shower or bath on arising.	Warmth reduces stiffness and relieves pain. Water should be warm. Excessive heat may promote skin breakdown.
Encourage the use of nonpharmacological measures of pain control such as relaxation, distraction, or guided imagery.	These measures may augment other medications used to diminish pain.
Suggest that the client apply a bed cradle.	Protective devices keep the pressure of bed covers off the inflamed lower extremities.
Instruct the client to take anti-inflammatory medications as prescribed. Explain the need for taking the first dose of the day as early in the morning as possible with a small snack.	The sooner the client takes the medication, the sooner the stiffness will abate. Anti-inflammatory drugs should not be taken on an empty stomach.
Suggest nonopioid analgesics as necessary.	Opiod analgesia appears to work better on mechanical pain and is not particularly effective in dealing with pain associated with inflammation. Opioids can be habit forming.
Consult an occupational therapist for the proper splinting of affected joints.	Specialty expertise may be required.
Encourage the client to wear splints as ordered.	Splints provide rest to inflamed joints and may reduce muscle spasm.

Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

May be related to

Anemia
Depression
Disease condition

Possibly evidenced by

Compromised concentration
Decreased performance
Excessive sleeping
Inability to restore energy even after sleep
Inability to maintain usual level of physical activity
Lack of energy, listless, tired

Desired Outcomes

Client will verbalize reduction in fatigue level, as evidenced by reports if increased energy and ability to perform desired activities.
Client will demonstrate the use of energy-conservation principles.

Nursing Interventions	Rationale
Assess the client’s description of fatigue: timing (Afternoon or all day), relationship to activities, and aggravating and alleviating factors.	This information may be helpful in developing and organizing patterns of activity that optimize the times when the client has the greatest energy reserve.
Determine whether fatigue is related psychological factors (e.g., stress, depression).	Fatigue is best treated by determining the causative factor. Depression is a common problem for people suffering from chronic disease, especially when the discomfort is an accompanying problem. Medications are available that are successful in treating clinical depression.
Determine the client’s nighttime sleep pattern.	The discomfort associated with systemic lupus erythematosus (SLE) may obstruct sleep.
Reinforce energy-conservation principles:
Adequate rest periods	Energy reserves may be depleted unless the client respects the body’s need for increased rest.
Pacing of activities (an alternating activity with rest)	The client often needs more energy than others to complete the same tasks.
Proper use of assistive and adaptive devices	Adequately used, these devices can support movement and activity, resulting in the conservation of energy.
Organization of activities and environment	Organization can help the client conserve energy and reduce fatigue.
If fatigue is related to interrupted sleep:
Instruct the client to avoid stimulating foods (caffeine) or activities before bedtime.	Environmental stimuli can inhibit relaxation, interrupt sleep, and contribute to fatigue.
Encourage a warm bath or washers immediately before bedtime.	Warm water relaxes the muscle, facilitating total body relaxation; excessive heat may promote skin breakdown.
Encourage the client to sleep in an anatomically correct position and not to prop up affected joints.	Good body alignment will result in muscle relaxation and comfort.
Encourage the use of progressive muscle-relaxation techniques.	These techniques promote relaxation and rest.
Encourage the client to frequently change position at night.	Repositioning promotes comfort.
Encourage gentle range-of-motion (ROM) exercises (after a shower or bath).	These exercises maximize the muscle-relaxing benefits of the warm shower or bath.
Administer a night time analgesic and/or a long-acting anti-inflammatory drug as prescribed.	The relief of pain can facilitate rest and sleep.

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

Complexity of treatment
Emotional state affecting learning
Misinterpretation of information
New condition or treatment
Unfamiliarity with information resources

Possibly evidenced by

Inaccurate follow-through on instructions
Multiple questions
Request for information
Verbalizing inaccurate information.

Desired Outcomes

Client will verbalize understanding of disease process and its treatment.

Nursing Interventions	Rationale
Assess the client’s knowledge of the disease, management, and complication.	Lack of knowledge about SLE and its chronic and progressive nature can compromise the client’s ability to care for self and cope effectively.
Educate the disease process information: unknown cause, chronicity of SLE, processes of inflammation and fibrosis, remissions and exacerbations, control versus cure.	The goal of treatment is to reduce inflammation, minimize symptoms and maintain normal body functions. The incidence of flares can be reduced by maintaining good nutrition and engaging in exercise habits.
Discuss common diagnostic tests.	A variety of immunologically based tests may be performed (e.g., antinuclear antibody [ANA], erythrocyte sedimentation rate [ESR], serum protein electrophoresis, rheumatoid factor, serum complement). Tests may also be indicated to assess for major organ or systemic involvement, such as kidney and liver assessments.
Introduce or reinforce information on drug therapy. Instruct the client in the potential side effects of steroids, immunosuppressant medication, and other drugs used to treat SLE.	Clients are better to be able to ask questions when they have basic information about what to expect.
Antimalarials (chloroquine, hydroxychloroquine)	These medications are used in the treatment of skin and joint symptoms of SLE. Side effects are rare, but our clients are cautioned to see their eye physician several times a year to rule out the development of irreversible retinopathy. Clients may also experience mild GI disturbances.
Corticosteroids	The classification of drugs is used for their anti-inflammatory and immunoregulatory properties (they suppress the activity of the immune system). Topical preparations are effective for skin problems. Oral-dose prednisone may be indicated for minor disease effects. Common side effects include facial puffiness, buffalo hump, diabetes mellitus, osteoporosis, avascular necrosis of the hip, increase cataracts, and an increased risk for infection.
Stress to the client the importance of not altering the steroid dose or suddenly stopping the medication.	Steroids must be tapered slowly after high-dose or long-term use. The body produces cortisol in the adrenal glands. After high dose or long-term use of exogenous forms of steroids, the body no longer produces adequate cortisol levels. Increased cortisol levels are needed in times of stress. Without supplementation, a steroid dependent client will enter an Addisonian crisis. The nurse must stress the importance of wearing a medical alert tag at all times that states the client uses steroids and immunosuppressants.
Nonsteroidal anti-inflammatory drugs and cyclooxygenase (COX-2) inhibitors	These drugs are used for their anti-inflammatory action. These agents should never be taken on an empty stomach. Side effects include gastrointestinal (GI) distress.
Immunosuppressants (mycophenolate mofetil, cyclophosphamide, azathioprine)	This classification of drug is used to suppress the activity of the immune system, thereby decreasing the proliferation of the disease, especially during severe flares and in renal or central nervous system involvement. Side effects include an increased infection risk caused by bone marrow suppression, nausea, and vomiting, sterility, hemorrhagic cystitis, and cancer.
Instruct the client to monitor for the signs of fever.	Fever is a common manifestation of SLE in the active phase of the disease. Clients should also report accompanying chills, shaking, and diaphoresis. Clients taking aspirin as an antipyretic should have frequent liver studies performed because aspirin use by clients with SLE has been demonstrated to cause transient liver toxicity.
Instruct in lifestyle activities that can help reduce flare-ups such as: Eating a balanced diet of fruits, grains, and vegetables. Regular exercise Avoiding sun exposure Adequate rest	A positive approach to useful therapies allows the client to be an active partner in treating this chronic condition.
Provide information on appropriate clinical trials.	New therapies for lupus are being researched all the time. Qualified clients may find hope and even relief from symptoms and complications.
Instruct in the opportunities for support groups in the community or on reputable internet websites.	Members of groups that come together for specialized problems can be helpful to each other.