7 Systemic Lupus Erythematosus Nursing Care Plans

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 diseases can affect the kidneys, heart, lungs, 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 and Management
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Nursing Care Plans and Management

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, increased knowledge regarding the disease, and absence of complications.

Nursing Problem Priorities

The following are the nursing priorities for patients with systemic lupus erythematosus (SLE):

Perform assessments to identify signs and symptoms of systemic lupus erythematosus (SLE).
Administer prescribed medications, such as corticosteroids or immunosuppressants, to manage disease activity.
Monitor and document disease progression, including organ involvement and complications.
Educate patients on the importance of medication adherence and potential side effects.
Provide support and guidance for managing symptoms and minimizing disease triggers.

Nursing Assessment

Assess for the following subjective and objective data:

See nursing assessment cues under Nursing Interventions and Actions.

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with systemic lupus erythematosus (SLE) based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

The client will verbalize the ability to cope with hair loss.
The client will identify measures to cover scalp loss as required by personal preference.
The client will maintain optimal skin integrity, as evidenced by an absence of rashes and skin lesions.
The client will report pain or stiffness at a level of less than 3 to 4 on a scale of 0 to 10.
The client will implement a pain management plan that includes pharmacological and nonpharmacological measures.
The client will be able to participate in self-care activities.
The client will verbalize understanding of the disease process and its treatment.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with systemic lupus erythematosus (SLE) may include:

1. Improving Skin Integrity

Improving skin integrity is an essential aspect of nursing care for patients with systemic lupus erythematosus (SLE). SLE can often cause skin manifestations, such as rashes, photosensitivity, and ulcers. These skin manifestations can have a significant impact on the patient’s quality of life and require special attention from healthcare providers

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 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 rays.

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 to 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.
Vitamins A and E may be useful in maintaining skin health.

For hair loss:

Instruct the client that scalp hair loss occurs during the 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.

2. Managing Acute Pain and Providing Relief and Comfort

SLE is a chronic autoimmune disease that can cause inflammation and damage to various organs and tissues, resulting in pain and discomfort. Acute pain episodes can occur due to disease flares, musculoskeletal involvement, or other complications associated with SLE.

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. Effective pain management is crucial to alleviate suffering and improve the patient’s quality of life.

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. The water should be warm. Excessive heat may promote skin breakdown.

Encourage the client to wear splints as ordered.
Splints provide rest to inflamed joints and may reduce muscle spasms.

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.
Opioid analgesia appears to work better on mechanical pain and is not particularly effective in dealing with the 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.

3. Decreasing Fatigue

Fatigue in SLE is often multifactorial, resulting from a combination of disease activity, medication side effects, sleep disturbances, and psychological factors. Managing and reducing fatigue is essential to improve the patient’s overall well-being and enhance their ability to engage in daily activities.

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 to 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 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 nighttime analgesic and/or a long-acting anti-inflammatory drug as prescribed
The relief of pain can facilitate rest and sleep.

4. Initiating Patient Education and Health Teachings

Patient education empowers individuals with SLE to actively participate in their own care, make informed decisions, and adopt healthy lifestyle behaviors. It equips them with the knowledge and skills necessary to recognize early signs of disease activity, manage medications, understand the importance of regular follow-up appointments, and implement self-care strategies.

Assess the client’s knowledge of the disease, management, and complication.
A 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, and 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 on 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. See Pharmacologic Management

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 doses 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.

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.

5. Administer Medications and Provide Pharmacologic Support

Administering medications and providing pharmacologic support are essential components of nursing care for patients with systemic lupus erythematosus (SLE). SLE requires a multifaceted approach to management, which often includes the use of various medications to control disease activity, manage symptoms, and prevent complications. Pharmacologic interventions play a critical role in alleviating symptoms, reducing inflammation, and suppressing the immune response.

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.

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.

6. Monitoring Results of Diagnostic and Laboratory Procedures

Diagnostic and laboratory procedures are crucial in diagnosing SLE, assessing disease activity, monitoring organ involvement, and guiding treatment decisions. Regular monitoring of procedures enables healthcare providers to evaluate the effectiveness of interventions, make necessary adjustments to the treatment plan, and detect potential complications or disease flares.

1. Antinuclear Antibody (ANA) Test
This blood test is used to detect the presence of antibodies that target the nucleus of cells. ANA is a primary screening test for SLE, as it is positive in the majority of SLE cases.

2. Anti-Double-Stranded DNA (anti-dsDNA) Antibody Test
This test measures the levels of antibodies specifically targeting double-stranded DNA. Anti-dsDNA antibodies are highly specific to SLE and can be helpful in confirming the diagnosis and monitoring disease activity.

3. Anti-Smith (anti-Sm) Antibody Test
This blood test detects antibodies targeting Smith antigen, which is highly specific for SLE. Anti-Sm antibodies are not present in all SLE patients but can aid in the diagnosis, particularly when combined with other clinical and laboratory findings.

4. Complement Component Tests
Complement proteins are part of the immune system and can be affected in SLE. Tests such as C3 and C4 complement levels, as well as CH50 (total hemolytic complement), are used to assess complement activity and help monitor disease activity.

5. Complete Blood Count (CBC)
This test measures the levels of red blood cells, white blood cells, and platelets. Patients with SLE often show signs of anemia, leukopenia (low white blood cell count), or thrombocytopenia (low platelet count).

6. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)
These tests help assess inflammation in the body. Elevated ESR and CRP levels can be seen in active SLE.

7. Kidney Function Tests
SLE can affect the kidneys, leading to conditions like lupus nephritis. Tests such as urine analysis, proteinuria measurement, and blood tests to assess kidney function (such as blood urea nitrogen and creatinine) are crucial for monitoring renal involvement.

8. Imaging Studies
Imaging techniques like X-rays, ultrasound, or computed tomography (CT) scans may be used to evaluate specific organ involvement or complications associated with SLE, such as joint damage or pleural effusions.

9. Biopsy
In certain cases, a tissue biopsy may be performed to confirm organ involvement or to assess disease activity. For example, a kidney biopsy may be conducted to diagnose and stage lupus nephritis.

7. Assessing and Monitoring for Potential Complications

1. Assess and monitor the patient for signs and symptoms of disease activity.
Assess and monitor the patient for signs and symptoms of disease activity, such as joint pain, skin rashes, fatigue, organ-specific symptoms (e.g., renal or cardiac), and changes in laboratory values. Regularly reviewing the patient’s medical history and conducting physical examinations can help identify any new or worsening symptoms, allowing for early intervention and appropriate management.

2. Monitor patient’s renal function.
SLE can affect the kidneys, leading to lupus nephritis or kidney damage. Regularly monitor the patient’s kidney function by assessing urine output, conducting urine analysis for proteinuria, and collaborating with the healthcare team to perform renal function tests (e.g., blood urea nitrogen, creatinine). Prompt detection of renal involvement enables timely interventions and referrals to nephrology specialists for further evaluation and management.

3. Assess patient’s skin condition.
Skin manifestations, such as rashes or photosensitivity, are common in SLE. Regularly assess the patient’s skin for any changes, including new rashes, lesions, or ulcerations. Documenting and reporting these findings to the healthcare provider can facilitate appropriate management and referral to dermatology specialists if necessary.

4. Monitor medication adherence and side effects.
SLE often requires complex medication regimens to manage symptoms and prevent disease flares. Ensure that the patient understands the importance of adhering to prescribed medications and provide education on potential side effects and adverse reactions. Regularly assess the patient for any medication-related side effects and promptly report them to the healthcare provider for appropriate adjustments or interventions.

5. Provide psychological and emotional support.
Living with a chronic illness like SLE can have a significant impact on a patient’s mental health and emotional well-being. Assess the patient’s psychological state regularly and provide emotional support. Encourage the patient to express concerns, fears, or stressors related to the disease and collaborate with the healthcare team to facilitate referrals for counseling or support groups as needed.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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