A CASE STUDY PRESENTATION ON

SYSTEMIC LUPUS ERYTHEMATOSUS

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Andig, Hussam
De Guia, Cher Kelly
Dimas, Norainah
Geographia, Kristyne Daphnie
Kauffman, Denise
Macabangun, Jamal
Macmod, Ommayah

March 2018
 TABLE OF CONTENTS

PAGE

I. TITLE PAGE i

II. TABLE OF CONTENTS ii

III. LIST OF TABLES iii

IV. LIST OF FIGURES iv

V. OBJECTIVES 1

General Objective

Specific Objectives

VI. INTRODUCTION 2

VII. DEFINITION OF TERMS 4

VIII. PHYSICAL EXAMINATION AND REVIEW OF SYSTEM 6

IX. CONCEPT MAPPING

X. NORMAL ANATOMY AND PHYSIOLOGY 10

XI. NURSING MANAGEMENT 11

XII. HEALTH EDUCATION PLAN 25

XIII. MEDICAL MANAGEMENT 27

XIV. REFERENCES 30

XV. APPENDICES

Diagnostic tests 9

Prognosis 29
 LIST OF TABLES

PAGE

1 Normal Anatomy and Physiology 10

Nursing Care Plans

3 Acute Pain 12

4 Fatigue 14

5 Impaired Skin Integrity 18

6 Body Image Disturbance 20

7 Knowledge Deficient 22
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OBJECTIVES

General Objectives:

At the end of one and a half – hour case presentation, the participants will be able to

explain the disease process of Systemic Lupus Erythematosus and its management.

Specific Objectives:

At the end of one and a half – hour case presentation, the participants will be able to:

1. Define the medical terms related to the case;

2. Discuss its risk factors, causes and manifestations;

3. Explain the anatomical structures and functions involved in a client with systemic lupus

erythematosus;

4. Elaborate the pathophysiology; and

5. Organize health teaching plans.

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INTRODUCTION

Systemic Lupus Erythematosus (SLE) is an inflammatory, autoimmune disorder that

affects nearly ever organ in the body. The overall incidence of SLE is estimated to be 1.8 to 7.6

per 100,000 persons, it occurs 6 to 10 times more frequently in women than in men and occurs 3

times more in African American populations than among Caucasians. In addition to SLE, many

other forms of adult lupus exist, including discoid lupus erythematosus (which is primarily affects

the skin on the face), subacute cutaneous lupus erythematosus (sun exposed areas affected with

sores), and drug-induced lupus (rarely includes brain or kidney effects and is usually temporary).

In periods of intense inflammatory activity, the widespread deposition of immune

complexes in sites like blood vessel walls produces inflammation and functional changes in

various organs, which gives the disease its systemic character. The disease process involves

chronic states where symptoms are minimal or absent and acute flares where symptoms and lab

results are elevated. Systemic symptoms include fever, malaise, weight loss, and anorexia. The

mucocutaneous, musculoskeletal, renal, nervous, cardiovascular, and respiratory systems are most

commonly involved. Less commonly affected are the gastrointestinal tract and liver as well as the

ocular system.

Some type of cutaneous system manifestations is experienced 80% to 90% of patents with

SLE. The most familiar skin manifestation (occurring in less than 50% of patients with SLE) is an

acute cutaneous lesion consisting of a butterfly-shaped erythematous rash across the bridge of the

nose and cheeks. Several other skin manifestations may occur in patients with SLE, including

subacute cutaneous lupus erythematous, which involves papulosquamous or annular polycyclic

lesions, and a discoid rash, which is a chronic rash with erythematous papules or plaques and
 3

scaling and can cause scarring in pigmentation changes. The Criteria for Classifying Systemic

Lupus Erythematosus is updated in 1997, and include four cutaneous, four systemic, and three

laboratory criteria. Diagnosis is determined by evaluating presenting signs and symptoms,

laboratory results, and patient’s medical history and medical history of family members. The ACR-

established criteria as follows: Malar rash, discoid rash, photosensitivity, oral ulcers, nonerosive

arthritis, pleuritic or pericarditis, kidney disease, neurologic disease, hematologic disease,

immunologic disorder and positive antinuclear antibody. Based on the 11 criteria, a person is

diagnosed with systemic lupus erythematosus if any 4 or more of the criteria are met at any time.

SLE can be life-threatening, but advances in its treatment have led to improved survival

and reduced morbidity. Acute disease requires interventions directed at controlling increased

disease activity or exacerbations that can involve any other organ system. Management of the more

chronic condition involves periodic monitoring and recognition of meaningful clinical changes

requiring adjustments in therapy. The mainstay of SLE treatment is based on pain management

and nonspecific immunosuppression. Therapy includes monoclonal antibodies, corticosteroids,

antimalarial agents, NSAIDs, and immunosuppressive agents. The most common nursing

diagnoses include fatigue, impaired skin integrity, body image disturbance, and deficient

knowledge for self-management decisions.

The purpose of this study is to expand the knowledge of the Systemic Lupus

Erythematosus, not only for us nursing students but for the people who don’t or do have SLE. For

them to know the common signs and symptoms and for us student nurses to encourage them to go

to their primary physician to confirm if they have SLE, because the early treatment can prevent

life-threatening situation.
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DEFINITION OF TERMS

Systemic Lupus Erythematosus - An inflammatory, autoimmune disorder that affects nearly

ever organ in the body.

Discoid Lupus Erythematosus - A chronic skin condition of sores with inflammation and

scarring favoring the face, ears, and scalp and at times on other body areas.

Subacute Cutaneous Lupus Erythematosus – A small, erythematous, scaly papular eruption in

a photosensitive distribution that subsequently leads to a psoriasiform or annular lesion,

Anorexia - An eating disorder characterized by an abnormally low body weight, an intense fear

of gaining weight and a distorted perception of weight.

Mucocutaneous - Relating to mucous membrane and skin; denoting the line of junction of the

two at the nasal, oral, vaginal, and anal orifices.

Acute Cutaneous Lesion - The most common form of cutaneous lesions of lupus associated

with systemic lupus erythematosus (SLE).

Papulosquamous – A condition which presents with both papules and scales, or both scaly

papules and plaques.

Malar Rash - A red or purplish facial rash with a “butterfly” pattern. It covers your cheeks and

the bridge of your nose, but usually not the rest of the face. The rash can be flat or raised.

Photosensitivity - An extreme sensitivity to ultraviolet (UV) rays from the sun and other light

sources.

Nonerosive Arthritis – Not characterized by erosion of tissue.

Positive Antinuclear Antibody - Antinuclear antibodies (ANA) are a group

of autoantibodies produced by a person's immune system when it fails to adequately distinguish

between "self" and "nonself." The ANA test detects these autoantibodies in the blood.
 5

Raynaud ’s phenomenon - A disease characterized by spasm of the arteries in the extremities,

especially the finger.

Arthralgias - Defined as any discomfort or pain in the joints (joint pain).

Nephritis – Inflammation of the kidneys.

Psychosis - A serious mental disorder characterized by a loss of contact with reality.

Alopecia - The partial or complete absence of hair from areas of the body where it normally

grows; baldness.

Pleuritis -
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PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

The American College of Rheumatology (ACR) established criteria for classification of systemic

lupus erythematosus (SLE) in 198. These were updated in 1997, and included four cutaneous,

four systemic and three laboratory criteria.

Diagnosis is determined by evaluating presenting signs and symptoms, laboratory results and the

patient’s medical history and medical history of family members. The ACR-established criteria

are as follows:

INTEGUMENTARY SYSTEM

 Malar rash (butterfly-shaped rash)

 Discoid rash

 oral ulcers

IMMUNE SYSTEM

 photosensitivity

 immunologic diease

MUSCULOSKELETAL SYSTEM

 nonerosive arthritis

RESPIRATORY/CARDIOVASCULAR SYSTEM

 pleuritis or pericarditis
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 pericarditis – most common cardiac manifestation

 myocarditis

 hypertension

 cardiac dysrhythmias

 valvular incompetence

URINARY SYSTEM

 kidney disease - nephritis

NEUROLOGIC SYSTEM

 neurologic disease – psychosis, cognitive impairment, seizures. peripheral and cranial

neuropathies, stroke

HEMATOLOGIC SYSTEM

 Hematologic disease

 positive antinuclear antibody

If any 4 or more of the criteria are met, a person is diagnosed with systemic lupus erythematosus.

Other manifestations include:

METABOLIC PROCESSES

 Fever

 Weight loss

 anorexia

MUSCULOSKELETAL
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 malaise

 arthralgias [joint pain; metacarpophalangeal (MCP) and proximal interphalangeal (PIP)

joints are the most commonly affected] or arthritis (synovitis) or both – common early

manifestation

 tenderness

 pain upon movement

INTEGUMENTARY

 papulosquamous or annular polycyclic lesions

 splinter hemorrhages

 alopecia

HEMA

 Raynaud’s phenomenon
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DIAGNOSTIC TESTS
 10

NORMAL ANATOMY AND PHYSIOLOGY

NORMAL ANATOMY STRUCTURES WITH THEIR DESCRIPTIONS AND FUNCTIONS

ANATOMICAL STRUCTURE DESCRIPTION

Bone Marrow  Takes over most hematopoietic functions,
although the final stages of the
differentiation of some cells may take place
in other organs. The red bone marrow is a
loose collection of cells where
hematopoiesis occurs, and the yellow bone
marrow is a site of energy storage, which
consists largely of fat cells.
Thymus  Is bilobed organ found in the space between
the sternum and the aorta of the heart.
 It generates mature T- lymphocytes (white
blood cells that help the immune system
fight off illness).
 Where T lymphocytes proliferate and
mature
Lymph nodes  Lymph nodes function to remove debris and
pathogens from the lymph and are thus
sometimes referred to as filters of the lymph.
Spleen  The spleen is a major secondary lymphoid
organ.
 Sometimes called filter of the blood because
of its extensive vascularization and the
presence of macrophages and dendritic cells
that remove microbes and other materials
from the blood.
Lymphoid Nodules  The other lymphoid tissue, the lymphoid
nodules, have simpler architecture than the
spleen and lymph nodes in that they consist
of a dense cluster of lymphocytes without a
surrounding fibrous capsule.
 These nodules are located in the respiratory
and digestive tracts, areas routinely exposed
to environmental pathogens.
Tonsils  Tonsils are lymphoid nodules located along
the inner surface of the pharynx and are
important in developing immunity to oral
pathogens.
 Such swelling is an indication of an active
immune response to infection.
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NURSING MANAGEMENT

The most common nursing diagnoses include fatigue, impaired skin integrity, body image
disturbance, and deficit knowledge for self-management decisions. The disease or its treatment
may produce dramatic changes in appearance and considerable distress for the patient.

 Patients with SLE report feeling of depression and anxiety as well as difficulty coping with the
disease and the financial strain associated with it.
 The patient may benefit from participation in support groups, which can provide disease
information, daily management tips, and social support.
 Because sun and ultraviolet light exposure can increase disease activity or cause an
exacerbation, patient should be instructed to avoid exposure or to protect themselves with
sunscreen and clothing.
 Because of the increased risk of involvement of multiple organ systems, patients should
understand the need for routine periodic screenings as well as health promotion activities.
 A dietary consultation may be indicated to ensure that the patient is knowledgeable about
dietary recommendations, given the increased risk of cardiovascular disease, including
hypertension and atherosclerosis.
 Smoking tobacco accelerates complications in patient with SLE. Patients diagnosed with SLE
are at even higher risk of developing lung cancer and other rare cancers. (Therefore, smoking
cessation programs should be offered to all patients who report smoking habits.
 The nurse educates the patient about the importance of continuing prescribed medications and
addresses the changes and potential side effects that are likely to occur with their use. The pt.
is reminded the importance of monitoring because of the increased risk of systemic
involvement, including renal and cardiovascular effects.
 Because of the immunosuppression associated with systemic corticosteroid usage, the nurse
must watch for signs and symptoms of infection, especially with acutely ill patients.
 The nurse should also screen the patient for osteoporosis, because long term use of
corticosteroids increases the incidence of osteoporosis. Patient should have a bone mineral
density test performed at diagnosis and prior to beginning steroid use to determine a baseline
status and then every 2 years thereafter.
 Educating the patient regarding calcium and vitamin D supplementation daily is encouraged,
along with the benefits of weight-bearing activities to support bone health.
 12

Acute Pain
ASSESSMENT NUSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Acute pain  Provide comfort  Pain may respond Client reported
Subjective: related to Within 30 minutes of measures such as to pain scale of
“My fingers are joint pain and nursing intervention, applying heat or cold nonpharmacologic less than 6,
painful.” swelling the client will be able compress, massage, interventions. showed signs of
associated to: position changes, improvement in
Pain scale:6/10 with the  Report pain scale of rest, use of comfort level,
disease less than 6. supportive pillows, acknowledged
Objectives: process relaxation techniques and
 Facial  Show signs of and diversional incorporated
grimace improvement in activities. pain
 Guarding comfort level. management
behavior  Encourage the use of  Crutches, walkers, techniques in
upon  Acknowledge and ambulation aids and canes can be daily life and
movement incorporate pain when pain is related used to absorb maintained
of affected management to weight-bearing. some of the weight necessary
joints techniques in daily from the inflamed measures to
 Pain- life. extremity. treat pain.
associated  Encourage client to  Activity is required
sounds  Maintain the avoid prolonged to prevent further
necessary measures periods of inactivity. stiffness and to
to treat pain. prevent joints from
freezing and
muscles from
becoming
atrophied.
 Administer anti-  These medications
inflammatory, treat the pain or
analgesics, swelling but can
corticosteroids also cause serious
 13

antimalarial agents, side effects

NSAIDs and slow- including organ
acting antirheumatic damage.
medications as
prescribed

 Consult physical  To maintain

therapist or mobility and range
encourage physical of motion without
therapy program. allowing the patient
to get overtired
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Fatigue
ASSESSMENT NUSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Actual Abnormal Fatigue related to After nursing a. Assess the client’s a. This information After nursing
Cues: immune system interventions, the description of fatigue: may be helpful in interventions, the
 Appears very tired pathology as client will be able timing (Afternoon or developing and client verbalized
and weak evidenced by to: all day), relationship to reduction in fatigue
organizing patterns
 Lethargic patient’s  Report activities, and level, as evidenced
of activity that
 Compromised appearance of improved sense aggravating and by reports of
weakness and of energy. alleviating factors. optimize the times increased energy
concentration and
mentation changes tiredness, when the client has and ability to
like disorientation to lethargy,  Perform the greatest energy perform desired
place, incoherent inability to activities of reserve. activities and
responses, and perform daily living and demonstrated the
focusing on the activities desired b. Determine whether use of energy-
b. Fatigue is best
feelings of weakness independently, activities at fatigue is related conservation
and poor muscle psychological factors treated by principles.
of her whole body level of ability.
determining the
 Inability to perform strength (e.g., stress,
activites of daily depression). causative factor.
living independently  Participate in Depression is a
 Poor muscle strength recommended common problem
 With health history treatment for people suffering
of easy fatigability program.
from chronic
and body weakness 7 disease, especially
months prior
when the
admission and with
decreased Hgb, Hct, discomfort is an
potassium and accompanying
sodium results of lab problem.
tests after Medications are
consultation to available that are
physician. successful in
 15

treating clinical
depression.

c. Determine the c. The discomfort

client’s nighttime sleep associated with
pattern. systemic lupus
erythematosus
(SLE) may obstruct
sleep.
d. Adequate rest d. Energy reserves
periods. may be depleted
unless the client
respects the body’s
need for increased
rest.
e. Pacing of activities e. The client often
(an alternating activity needs more energy
with rest). than others to
complete the same
tasks.

f. Proper use of f. Adequately used,

assistive and adaptive these devices can
devices support movement
and activity,
resulting in the
conservation of
energy.
 16

g. Organization of g. Organization can

activities and help the client
environment. conserve energy
and reduce fatigue.

h. Environmental
stimuli can inhibit
h. Instruct the client to relaxation, interrupt
sleep, and
avoid stimulating
contribute to
foods (caffeine) or fatigue.
activities before
bedtime.

i. Encourage a warm i. Warm water

relaxes the muscle,
bath or washers facilitating total
immediately before body relaxation;
excessive heat may
bedtime. promote skin
breakdown.

j. Encourage the client j. Good body

to sleep in an alignment will
result in muscle
anatomically correct relaxation and
position and not to comfort.
prop up affected joints.
 17

k. These techniques
k. Encourage the use of
promote relaxation
progressive muscle- and rest.
relaxation techniques.

l. Encourage the client l. Repositioning

to frequently change promotes comfort.

position at night.

m. Encourage gentle m. These exercises

maximize the
range-of-motion muscle-relaxing
(ROM) exercises (after benefits of the
warm shower or
a shower or bath). bath.
n. Administer a night n. The relief of pain
time analgesic and/or a can facilitate rest
long-acting anti- and sleep.
inflammatory drug as
prescribed.
 18

Impaired Skin Integrity

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Impaired After an hour of  Assess skin for integrity  Small lesions may After nursing
 Rashes Skin Integrity nursing intervention, develop on the oral and interventions, the
 Hair fall the client will: nasal mucous membrane. client:
 Dry skin
 Crack lips  Verbalize ability  Assess for an  The classic “butterfly rash  Verbalized
 Oral ulcers to cope with hair erythematous rash, which may appear across the ability to cope
loss may be present on the face, bridge of the nose and on with hair loss
 Client will neck, or extremities. the cheeks and is  Identified
identify measures characteristically measures to
to cover scalp loss displayed in configuration cover scalp loss
as required by of a butterfly as required by
personal personal
preference preference
 Client will  Encourage adequate  These measures promote  Maintained
maintain optimal nutrition and hydration healthy skin and healing optimal skin
skin integrity, as in the presence of wounds integrity, as
evidence by an evidence by an
absence of rashes  Instruct the client to clean,  Scented lotions may absence of
and skin lesions. dry, and moisture intact contain alcohol, which rashes and skin
skin; use warm (not hot) dries the skin. Prescribe lesions
water, especially over solutions reduce dryness
bony prominences; use of the scalp and maintain
unscented lotion. Use a skin integrity.
mild shampoo.

 Instruct the client to avoid  These foods might irritate

spicy or citrusy foods. fissures or ulcers in the
mucous membranes.

 Instruct the client to keep
ulcerated skin clean and
dry. Apply dressings as
needed.
 Instruct the client that
scalp hair loss occurs
during exacerbation of
disease activity.
19
 Skin is necessary to
prevent infection and
promote healing.
 Scalp hair loss may be the
first sign of impeding
disease exacerbation.
Scalp hair loss may not be
permanent. As disease
activity subsides, scalp
hair begins to regrow.
 20

Body Image Disturbances

ASSESSMENT NUSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective: Independent:
“I’m so insecure Disturbed body After 30 minutes of  Establish  In this situation  The patient
about my rashes” image r/t illness nursing therapeutic nurse- the patient can’t verbalized her
secondary to rashes interventions, the client relationship, easily open up understanding
Objectives: patient will lessen conveying an but when the of body changes
the body attitude of caring rapport is due to her
 Positive disturbances and developing a established, illness
 butterfly rash manifested by: sense of trust trust will gain  Butterfly rash
 Rashes on the  Verbalize prevented using
neck, chest, backs understanding  Evaluate the  This may sunscreen with
of upper arms of body changes client’s indicate if the high spf
 Hair loss  Verbalize knowledge of and patient has  Decided to seek
 Swollen lymph acceptance of anxiety related to acceptance or information to
nodes self in situation situation. no actively pursue
 Seek Observed growth
Percussion: information and emotional
 Abdomen was actively pursue changes.
non-tender to growth  Have client  This way we
palpation  Acknowledge describe self, can know if the
 Palpation of self as an noting what is self-esteem is
lymph nodes individual has positive and low or no
revealed rubbery responsibility negative. Be
axillary & for self aware how the
inguinal patient believes
lymphadenopathy others see self.
Systemic Lupus  Observe the  Distortions in
Activity Measure- interaction of the image may be
Revised (SLAM-R): patient through unconsciously
20/81 her SO’s reinforced by
 21

family members
and/or
secondary gain
issues may
interfere in
process

 Visit client  This provides

frequently and opportunities
acknowledge the for listening to
individual as concerns and
someone who is questions of the
worthwhile. patients

Collaborative:
 Note signs of  To evaluate
grieving/indicators need of
of severe counseling
prolonged and/or
depression medications
 22

Knowledge Deficit

ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Knowledge After an hour - Assess the client’s knowledge of the - -Lack of knowledge about After an hour of health
Deficit related of health disease, management, and SLE and its chronic and teaching, the patient was able
“I am aware of my to teaching, the complication. progressive nature can to verbalized the importance of
condition but my Unfamiliarity- client will: having the knowledge of the
compromise the client’s
knowledge is not ty with condition.
enough and I don’t information - Verbalize ability to care for self and
know the things to resources understand cope effectively.
be done and ing of
avoid” as disease - -The goal of treatment is to
- Educate the disease process
verbalized by the process reduce inflammation,
information: unknown cause,
Pt and its minimize symptoms and
treatment chronicity of SLE, processes of
maintain normal body
Objective: - Verbalize inflammation and fibrosis, remissions
functions. The incidence of
- Inaccurate the and exacerbations, control versus cure.
flares can be reduced by
follow-through on knowledge
instructions gained maintaining good nutrition
about the and engaging in exercise
-Multiple condition habits.
questions
- Discuss common diagnostic tests. - -A variety of
- Request for immunologically based tests
information may be performed (e.g.,
[ANA], [ESR], serum protein
-Verbalizing electrophoresis, rheumatoid
factor, serum complement).
inaccurate Tests may also be indicated
to assess for major organ or
information
systemic involvement, such
as kidney and liver
assessments.

- Clients are better to be able

- Introduce or reinforce information on
to ask questions when they
drug therapy. Instruct the client in the
 23

potential side effects of steroids, have basic information about

immunosuppressant medication, and what to expect.
other drugs used to treat SLE.

- -Fever is a common
- Instruct the client to monitor for the manifestation of SLE in the
signs of fever. active phase of the disease.
Clients should also report
accompanying chills,
shaking, and diaphoresis.

- -A positive approach to
- Instruct in lifestyle activities that can
useful therapies allows the
help reduce flare-ups such as:
client to be an active partner
>Eating a balanced diet of fruits, grains, in treating this chronic
and vegetables. condition.

>Regular exercise

>Avoiding sun exposure

>Adequate rest

-Instruct in the opportunities for support - -Members of groups that

groups in the community or on reputable come together for specialized
internet websites. problems can be helpful to
each other.
 24

HEALTH EDUCATION PLAN (HEP)

Objectives:
At the end of 1 hour and 30 minutes lecture the client will be able to:
1. Identify the clinical manifestation of SLE;
2. Demonstrate the exercises such as warm up, cool down, stretching and breathing exercise;
3. Recall important clothes to wear to protect yourself outdoors;
4. Discuss the important of taking medication; and
5. Enumerate the required diet and nutrition needed for SLE patient.

General Health Teaching Specific Health Teaching

1. Danger signs of Systemic Lupus a. Butterfly-shaped rash on the face that covers the cheeks and bridge of
Erythematosus the nose or rashes elsewhere on the body.
b. Fatigue, Fever, Joint pain, stiffness and swelling
c. Skin lesions that appear or worsen with sun exposure (photosensitivity)
d. Fingers and toes that turn white or blue when exposed to cold or during
stressful periods (Raynaud's phenomenon)
e. Shortness of breath, Chest pain and Dry eyes

2. Exercise a. Talk to your doctor — Many people with arthritis can successfully
exercise on their own. Before beginning an exercise program, contact
your doctor or other health care provider to be sure it is safe.
b. Warm up — The purpose of the warm-up is to improve circulation and
to increase the temperature of muscles and joint structures so that the
body is less stiff, movement is easier, and risk of injury is decreased. If
you are successful, your body will feel slightly warmer than when you
started. Stretching is best done after your exercise session as part of
your cool down.
c. Cool down — the purpose of the cool-down is to return your heart rate
to a few beats above normal. This prevents a sudden drop in blood
pressure, feelings of nausea, fainting, and dizziness.
d. Stretching — Stretching returns muscles to their full length and reduces
soreness after exercise. People with arthritis need to be more cautious if
 25

they have lax joints (extra mobility or hyper-flexibility) or malaligned

joints (eg, hand deformities, bowlegged). Flexibility exercises can
include modified yoga and tai chi (a Chinese martial art that involves
slow, gentle movements), as well as stretches.
e. Breathing exercise — Be sure to include breathing exercises in your
exercise program; this helps to improve mobility and chest expansion.
3. Clothing a. Wear cool and dry clothes.
b. For better protection choose long-sleeve shirts, long pants
c. Use sunglasses when expose under the heat of the sun.
d. Apply sunscreen when body parts are exposing to the sun.
e. Do not stay too long under

4. Medications a. Nonsteroidal anti-inflammatory drugs (NSAIDS). These can be used to

help relieve swelling, pain, and fever.
b. Antimalarial medicine. A medicine used to prevent and treat malaria
can help ease some lupus symptoms. It can treat fatigue, rashes, joint
pain, and mouth sores. The medicine may also help prevent blood clots.
c. Corticosteroid medicines. These can help people when lupus affects the
kidneys, lungs, or heart, or nervous system.
d. Medicines that suppress the immune system. These can help treat
severe symptoms of lupus that has attacked organs.
e. Belimumab, a biologic medicine, may be helpful in some people.

5. Diet and nutrition a. Eat a balanced diet consisting of a variety of foods - this would include
increasing your intake of fish, fresh fruit and vegetables, unprocessed
cereals and grains, low-fat milk and yoghurt.
b. Make sure that you are drinking sufficient liquid. Increase fluid intake
to avoid being dehydrated.
c. Don’t eat too much protein as this may aggravate SLE. Use fish instead
of red meat, chicken and organ meats to increase your omega-3 intake.
d. Decrease sodium intake
 26

e. Try to maintain your ideal body weight. If you are overweight, ask your
dietician to help you lose weight by reducing your energy intake.
f. Do not exclude certain food groups unless your doctor or dietician has
advised you to do so.
 27

MEDICAL MANAGEMENT

The goals of treatment include preventing progressive loss of organ function, reducing the
likelihood of acute disease, minimizing disease-related disabilities, and preventing complication
from therapy. Management of SYSTEMIC LUPUS ERYTHEMATOSUS involves regular
monitoring to assess disease activity and therapeutic effectiveness.

PHARMACOLOGIC THERAPY

 Belimumab (Benlysta)
- Is approved by the FDA for the treatment of SLE.
- Belimumab is a monoclonal antibody that specifically recognizes and binds to BLyS.
- Research suggest that Belimumab reduces disease activity and flares in patients with SLE
- Live vaccines are contraindicated while taking this medication, and caution should be
used with all concurrent medications given the short duration that belimumab has been
available.
 Cortiscosteroids
- Another medication used topically for cutaneous manifestations.
- In low oral doses for minor disease activity, and in high doses for major disease activity
- Intravenous (IV) administration of corticosteroids is an alternative to traditional hogh-
dose oral administration.
- One of the most important risk factors associated with the use of corticosteroids in SLE is
osteoporosis and fractures.
 Hydroxychloroquine
- An antimalarial medication approved by FDA
- Is effective for managing cutaneous, musculoskeletal, and mild systemic features of SLE
- The NSAIDs used for minor clinical manifestation are often used in conjunction with
corticosteroids in an effort to minimize corticosteroid requirements.
 Immunosuppressive agents (alkylating agents and purine analogues)
- Are used because of their effect on overall immune function.
- These medications are generally reserved for patients who have serious forms of SLE that
have not responded to conservative therapies.
- Examples include cyclophosphamide azathioprine, mycophenolic acid (Myfortic), and
methotrexate, which are contraindicated in pregnancy and have been used most
frequently in SLE nephritis.
 28

PROGNOSIS

Systemic lupus erythematosus (SLE) is still a disease with significant mortality. Although
5 yr after diagnosis 92% of patients are alive, the prognosis falls to 82% survival at 10 yr, 76% at
15 yr and only 68% at 20 yr in Toronto. There has been improvement in survival, with the
standardized mortality ratio in patients recruited to the Toronto cohort in 1970–1977 being 10.1
(95% CI 6.5–15.0), compared with 3.3 (95% CI 1.8–5.7) for those recruited between 1986 and
1994. Data from other centres in the USA and Europe has been similar. Studies published around
1980 found that about 80% of patients survived 5 yr and about 60% of patients survived 10 yr.
More recent studies have shown that 5‐yr survival is now nearer 90–95% and that 70–85% of
patients survive 10 yr. In most studies, patients with renal involvement have had a poorer prognosis
than those without renal disease. Nevertheless, survival has shown improvement in those with
renal disease presenting to a UK centre between 1976 and 1986 (81% 10‐yr survival), compared
with those presenting between 1963 and 1975 (56% 10‐yr survival).
 29

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