265 Exam 4 Review.
18: ARTHRITIS AND COMMON TISSUE DISEASES
LUPUS ERYTHEMATOSUS (DLE/SLE)
>>> PATHO
• Lupus is probably caused by a complex combo of genetic and environmental factors
• 2 main classifications:
o Discoid lupus erythematosus (DLE) – effects only the skin
o Systemic lupus erythematosus (SLE) – more common
• Systemic lupus erythematosus (SLE):
o Chronic, progressive, inflammatory connective tissue disorder that can
cause major body organs/systems to fail
o Spontaneous remissions and exacerbations
o Onset may be acute or insidious (slow)
o Potentially fatal, but most live many years
o Autoimmune process – invades organs or deprives them of blood and oxygen
o Immune complexes invade organs directly or cause vasculitis (vessel
inflammation), which deprives the organs of arterial blood and
oxygen.
o Autoimmune complexes tend to be attracted to glomeruli of the kidneys
o Often some degree of kidney involvement (lupus nephritis) – this is the
leading cause of death from this disease
o Onset at 20-40 years old
>>> ASSESSMENT
>> PHYSICAL ASSESSMENT
• When in remission pt. may
appear fully healthy
• When disease flares up, pt. may
need to be admitted to the
hospital
• MT skin condition daily and at
every home visit
1
, 265 Exam 4 Review.
CHART 18-11 KEY FEATURES – SLE AND SSc
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) SYSTEMIC SCLEROSIS (SSc)
SKIN Inflamed, red rash on face Inflamed
(“butterfly rash”) Fibrotic
- can appear on other sun- Sclerotic
exposed areas Edematous
- disappears when in remission
Discoid lesions
- worsen when exposed to sunlight
or UV light
- do not disappear, but fade in
remission
RENAL Nephritis Kidney failure
CARIAC Pericarditis (chest pain, SOB, fever) Myocardial fibrosis
Raynaud’s phenomenon (decreased Raynaud’s phenomenon
blood flow to fingers) Deep vein thrombosis
PULMONARY Pleural effusions (accumulation of fluid Interstitial fibrosis
around the lungs) Pulmonary HTN
Pneumonia
NEURO CNS lupus Not common
GI Abd. pain Esophagitis
Ulcers
GERD
MUSCLE Joint inflammation (polyarthritis) Arthralgia
Myositis Myositis
OTHER Fever (indicates exacerbation) Fever
Fatigue Fatigue
Anorexia Anorexia
Weight loss Vasculitis
Generalized weakness
Vasculitis
Osteonecrosis (bone necrosis from lack
of oxygen)
- most common in the hip
>> PSYCHOSOCIAL ASSESSMENT
2
, 265 Exam 4 Review.
• Psychosocial results can be devastating
• Chronic weakness and fatigue may prevent pt. from being as active
• May avoid social gatherings
• Fear and anxiety from unpredictability
• Limit sun exposure to prevent exacerbations
>> LABS
• Skin biopsy – confirms diagnosis
o MD scraps skin cells from rash to be looked at under a microscope
• Immunologic-based lab tests – same as rheumatoid arthritis
• CBC – often shows pancytopenia (a decrease of all cell types)
• Electrolytes
• Kidney fx.
• Cardiac and liver enzymes
• Clotting factors
>>> INTERVENTIONS
• The primary health care provider often prescribes potent drugs that are used
topically and systemically
• Many of the skin lesions do not disappear with treatment, but will usually fade when in
remission
>> DRUG THERAPY
• DLE major concern is the rash or discoid lesions
• Topical cortisone drugs – help reduce inflammation and promote fading of lesions
• Tylenol or NSAIDs – treat joint and muscle pain and inflammation
• Hydroxychloroquine – decreases the absorption of UV light by the skin,
therefore decreasing the risk for skin lesions
o Eye exams before starting drug and every 6 months while on it
• Chronic steroid therapy – treats the systemic disease process
• Immunosuppressive agents (methotrexate or azathioprine) – for renal of CNS lupus
o Continue to take while in remission to help prevent more exacerbations
• Chronic lupus = low dose steroids forever
• DRUG ALERT!! – when taking steroids or immunosuppressants avoid large crowds
and ill people. Report early S/S of infection to DR, take meds early in the morning
before breakfast (time when the body’s natural corticosteroid level is lowest)
3
, 265 Exam 4 Review.
• For severe renal involvement, immunosuppressants may be given in combo
with steroids
• New drugs:
o Lupozor
o Belimumab (Benlysta)
▪ Increases risk for infection
▪ Do not receive live viruses for 30 days before tx.
>> PROTECTING THE SKIN
• PROTECT SKIN TO PREVENT AN EXACERBATION
• ACTION ALERT!! – Avoid prolonged exposure to sunlight and other forms of UV
light, wear long sleeves and large-brimmed hat when outdoors, use sunblock SPF 30
or higher.
• CHART 18-12 SKIN PROTECTION FOR LUPUS ERYTHEMATOSUS
o Wash with mild soap (Ivory) and dry skin thoroughly by patting NOT rubbing.
o Avoid harsh perfumed substances
o Cosmetics should include moisturizers and sun protectant
o Use lotions
o Avoid powders, rubbing alcohol, and drying agents.
o Use gentle shampoos and avoid harsh hair treatments (Alopecia/hair loss
is common)
o Avoid direct sunlight and ultraviolet light including tanning beds
o Wear long sleeves, wide-brimmed hats, long pants when in the sun
o Use sunscreen – SPF 30 or higher
o Inspect skin daily for rashes and lesions.
CARE MANAGEMENT
• 2 major differences exist between SLE and rheumatoid arthritis (RA) in terms
of education of the pt. and family
o 1. SLE – how to protect the skin
o 2. SLE – MT body temp. (fever is a major S/S of exacerbation)
• Teach the importance of reporting any other unusual or new S/S to the primary
MD immediately.
• Identify coping strategies and support systems for the unpredictability of this condition –
fear and anxiety
• Pregnancy can be a stressor that causes an exacerbation (during and after birth)
o Increased risk for stillbirth, miscarriage, and premature birth
4
18: ARTHRITIS AND COMMON TISSUE DISEASES
LUPUS ERYTHEMATOSUS (DLE/SLE)
>>> PATHO
• Lupus is probably caused by a complex combo of genetic and environmental factors
• 2 main classifications:
o Discoid lupus erythematosus (DLE) – effects only the skin
o Systemic lupus erythematosus (SLE) – more common
• Systemic lupus erythematosus (SLE):
o Chronic, progressive, inflammatory connective tissue disorder that can
cause major body organs/systems to fail
o Spontaneous remissions and exacerbations
o Onset may be acute or insidious (slow)
o Potentially fatal, but most live many years
o Autoimmune process – invades organs or deprives them of blood and oxygen
o Immune complexes invade organs directly or cause vasculitis (vessel
inflammation), which deprives the organs of arterial blood and
oxygen.
o Autoimmune complexes tend to be attracted to glomeruli of the kidneys
o Often some degree of kidney involvement (lupus nephritis) – this is the
leading cause of death from this disease
o Onset at 20-40 years old
>>> ASSESSMENT
>> PHYSICAL ASSESSMENT
• When in remission pt. may
appear fully healthy
• When disease flares up, pt. may
need to be admitted to the
hospital
• MT skin condition daily and at
every home visit
1
, 265 Exam 4 Review.
CHART 18-11 KEY FEATURES – SLE AND SSc
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) SYSTEMIC SCLEROSIS (SSc)
SKIN Inflamed, red rash on face Inflamed
(“butterfly rash”) Fibrotic
- can appear on other sun- Sclerotic
exposed areas Edematous
- disappears when in remission
Discoid lesions
- worsen when exposed to sunlight
or UV light
- do not disappear, but fade in
remission
RENAL Nephritis Kidney failure
CARIAC Pericarditis (chest pain, SOB, fever) Myocardial fibrosis
Raynaud’s phenomenon (decreased Raynaud’s phenomenon
blood flow to fingers) Deep vein thrombosis
PULMONARY Pleural effusions (accumulation of fluid Interstitial fibrosis
around the lungs) Pulmonary HTN
Pneumonia
NEURO CNS lupus Not common
GI Abd. pain Esophagitis
Ulcers
GERD
MUSCLE Joint inflammation (polyarthritis) Arthralgia
Myositis Myositis
OTHER Fever (indicates exacerbation) Fever
Fatigue Fatigue
Anorexia Anorexia
Weight loss Vasculitis
Generalized weakness
Vasculitis
Osteonecrosis (bone necrosis from lack
of oxygen)
- most common in the hip
>> PSYCHOSOCIAL ASSESSMENT
2
, 265 Exam 4 Review.
• Psychosocial results can be devastating
• Chronic weakness and fatigue may prevent pt. from being as active
• May avoid social gatherings
• Fear and anxiety from unpredictability
• Limit sun exposure to prevent exacerbations
>> LABS
• Skin biopsy – confirms diagnosis
o MD scraps skin cells from rash to be looked at under a microscope
• Immunologic-based lab tests – same as rheumatoid arthritis
• CBC – often shows pancytopenia (a decrease of all cell types)
• Electrolytes
• Kidney fx.
• Cardiac and liver enzymes
• Clotting factors
>>> INTERVENTIONS
• The primary health care provider often prescribes potent drugs that are used
topically and systemically
• Many of the skin lesions do not disappear with treatment, but will usually fade when in
remission
>> DRUG THERAPY
• DLE major concern is the rash or discoid lesions
• Topical cortisone drugs – help reduce inflammation and promote fading of lesions
• Tylenol or NSAIDs – treat joint and muscle pain and inflammation
• Hydroxychloroquine – decreases the absorption of UV light by the skin,
therefore decreasing the risk for skin lesions
o Eye exams before starting drug and every 6 months while on it
• Chronic steroid therapy – treats the systemic disease process
• Immunosuppressive agents (methotrexate or azathioprine) – for renal of CNS lupus
o Continue to take while in remission to help prevent more exacerbations
• Chronic lupus = low dose steroids forever
• DRUG ALERT!! – when taking steroids or immunosuppressants avoid large crowds
and ill people. Report early S/S of infection to DR, take meds early in the morning
before breakfast (time when the body’s natural corticosteroid level is lowest)
3
, 265 Exam 4 Review.
• For severe renal involvement, immunosuppressants may be given in combo
with steroids
• New drugs:
o Lupozor
o Belimumab (Benlysta)
▪ Increases risk for infection
▪ Do not receive live viruses for 30 days before tx.
>> PROTECTING THE SKIN
• PROTECT SKIN TO PREVENT AN EXACERBATION
• ACTION ALERT!! – Avoid prolonged exposure to sunlight and other forms of UV
light, wear long sleeves and large-brimmed hat when outdoors, use sunblock SPF 30
or higher.
• CHART 18-12 SKIN PROTECTION FOR LUPUS ERYTHEMATOSUS
o Wash with mild soap (Ivory) and dry skin thoroughly by patting NOT rubbing.
o Avoid harsh perfumed substances
o Cosmetics should include moisturizers and sun protectant
o Use lotions
o Avoid powders, rubbing alcohol, and drying agents.
o Use gentle shampoos and avoid harsh hair treatments (Alopecia/hair loss
is common)
o Avoid direct sunlight and ultraviolet light including tanning beds
o Wear long sleeves, wide-brimmed hats, long pants when in the sun
o Use sunscreen – SPF 30 or higher
o Inspect skin daily for rashes and lesions.
CARE MANAGEMENT
• 2 major differences exist between SLE and rheumatoid arthritis (RA) in terms
of education of the pt. and family
o 1. SLE – how to protect the skin
o 2. SLE – MT body temp. (fever is a major S/S of exacerbation)
• Teach the importance of reporting any other unusual or new S/S to the primary
MD immediately.
• Identify coping strategies and support systems for the unpredictability of this condition –
fear and anxiety
• Pregnancy can be a stressor that causes an exacerbation (during and after birth)
o Increased risk for stillbirth, miscarriage, and premature birth
4
