4 Systemic Lupus Erythematosus Nursing Care Plans

Impaired Skin Integrity

Nursing Diagnosis

• Impaired Skin Integrity

May be related to

• Exacerbation of the 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 ulcers
• Pain and tenderness
• Redness
• Scalp hair loss possibly accompanied by lesions, scarring, or dry, scaling skin tissue
• Skin breakdown
• Skin rash

Desired Outcomes

• 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.

Nursing Assessment and Rationales

1. 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.

2. Assess the client’s description of pain.
Gathering information about pain can guide treatment. Each client may exhibit slightly different presentations.

3. 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.

4. 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.

5. 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.

Nursing Interventions and Rationales

1. Encourage adequate nutrition and hydration.
These measures promote healthy skin and healing in the presence of wounds.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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 a 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.