Medsurge2 Nursing265 Exam 4 Study 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
,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 .Sclerotic
.sun- .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 .Vasculitis
.loss
Generalized .weakness
.Vasculitis
Osteonecrosis .(bone .necrosis .from .lack .of
.oxygen)
- .most .common .in .the .hip
>> .PSYCHOSOCIAL .ASSESSMENT
, • 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)
, • 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
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
,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 .Sclerotic
.sun- .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 .Vasculitis
.loss
Generalized .weakness
.Vasculitis
Osteonecrosis .(bone .necrosis .from .lack .of
.oxygen)
- .most .common .in .the .hip
>> .PSYCHOSOCIAL .ASSESSMENT
, • 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)
, • 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
