Question

D.W. is a 25-year-old married woman with three children under 5 years old. She was first seen by her physician months ago with vague complaints of intermittent fatigue, joint pain, low-grade fever, and unintentional weight loss. Her physician noted small, patchy areas of vitiligo and a scaly rash across her nose, cheeks, back, and chest at that time.

Laboratory studies at that time revealed that D.W. had a positive antinuclear antibody (ANA) titer, positive dsDNA (positive lupus erythematosus), positive anti-Sm (anti-smooth muscle antibody), elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and decreased C3 and C4 serum complement. Joint x-ray films demonstrated joint swelling without joint erosion.

D.W. was subsequently diagnosed with systemic lupus erythematosus (SLE). She was initially treated with hydroxychloroquine (Plaquenil) 400 mg and Deltasone (Prednisone) 20 mg orally per day, bed rest, and ice packs. D.W. responded well to treatment, the steroid was tapered and discontinued, and she was told she could report for follow-up every 6 months unless her symptoms became acute. D.W. resumed her job in environmental services at a large geriatric facility.

D.W. was seen in the immunology clinic twice monthly during the next 3 months. Although her condition did not worsen, her BUN and creatinine remained elevated. While at work one afternoon, D.W. begins to feel dizzy and develops a severe headache. She reported to her supervisor, who had her lie down. When D.W. started to become disoriented, her supervisor called 911, and D.W. was taken to the hospital. D.W. is admitted for probable lupus cerebritis related to acute exacerbation of her disease.

Current Laboratory Test Results

• Sodium 129 mmol/L
• Potassium 4.2 mmol/L
• Chloride 119 mmol/L
• Total CO 2 21 mmol/L
• BUN 34 mg/dL
• Creatinine 2.6 mg/dL
• Glucose 123 mg/dL
• Urinalysis 2 + protein
• 1 + RBCs

1. What is the significance of D.W.'s laboratory findings from her initial workup?

2. Given that most tests are nonspecific, how is SLE diagnosed?

3. What priority problems were addressed in D.W.'s care plan at that time of diagnosis?

4. Which current laboratory findings concern you, and why?

5. Detail D.W.'s expected treatment plan and nursing interventions. Include complications associated with immunosuppression therapy.

Answer 1

Ans) 1) The significance of each of D.W.'s laboratory findings:

- Positive antinuclear antibody (ANA) titer:

• Auto-antibodies are in the immune system.

- Positive dsDNA (positive lupus erythematosus):

• Auto- antibodies that target DNA
• Highly specific

- Positive anti- SM (smooth muscle antibody):

• Presence of antibodies against smooth muscle

- Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR):

• Measure of inflammation in the body

- Decreased C3 and C4 serum complement:

• Shows impending or current "flare" of lupus symptoms.

2) Criteria for SLE: Established by the American Rheumatism association- If individual displays 4 or more of this criteria, SLE diagnosis is highly suggested.

Malar- purplish/ moldy scaly rash over the cheeks and nose:

- Known as butterfly rash

- D.W.displays scaly rash over cheeks, nose, back and chest.

- Discoid skin rash

- Photosensitivity

- Two or more swollen/ tender joints

• shown both subjectively and objectively

- Brain Irritation

• Seizure or psychosis

- Mucous membrane ulcers

- Pleuritis or pericarditis

- Low blood counts

- Kidney abnormalities

• proteinuria

-Test:

• dsDNA, anti-SM, ANA
• ESR and CRP

3) Priority problems that are identified in D.W's care plan at the time of Diagnosis:

- Coping and understanding of DX

- Monitor pain and temperature

- Medication administration and understanding

- Ways to live a normal and save life DX w/SLE

4) Concerned laboratory findings are:

- Elevated BUN andbcreatinine

- Proteinuria and hematuria

- Slightly elevated sodium and chloride.