Systemic Lupus Erythematosus (SLE or Lupus) is a chronic autoimmune disease that can affect multiple body systems, causing inflammation and damage to tissues and organs. This nursing diagnosis focuses on identifying and managing lupus symptoms, preventing complications, and improving the quality of life for patients with lupus.
Causes (Related to)
Lupus can affect patients in various ways, with several factors contributing to its severity and progression:
- Autoimmune response attacking healthy tissue
- Genetic predisposition
- Environmental triggers such as:
- UV light exposure
- Certain medications
- Infections
- Stress
- Hormonal changes
- Risk factors including:
- Gender (more common in women)
- Age (15-44 years)
- Race (more common in African Americans, Hispanics, and Asians)
- Family history
Signs and Symptoms (As evidenced by)
Lupus presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Joint pain and stiffness
- Extreme fatigue
- Unexplained fever
- Skin rashes, especially butterfly rash
- Photosensitivity
- Muscle pain
- Headaches
- Depression or anxiety
- Memory problems
Objective: (Nurse assesses)
- Malar rash across cheeks and nose
- Discoid rashes
- Joint swelling
- Hair loss
- Oral or nasal ulcers
- Abnormal laboratory values
- Pleural or pericardial effusion
- Proteinuria
- Anemia
Expected Outcomes
The following outcomes indicate successful management of lupus:
- The patient will report decreased pain levels
- The patient will demonstrate improved energy levels
- The patient will maintain stable vital signs
- The patient will show no signs of organ involvement
- The patient will demonstrate proper self-management techniques
- The patient will maintain optimal functional status
- The patient will avoid triggers and complications
Nursing Assessment
Monitor Vital Signs
- Check temperature, pulse, blood pressure, and respiratory rate
- Note any signs of inflammation or infection
- Monitor for cardiovascular complications
Assess Pain and Fatigue Levels
- Document the location and intensity of the pain
- Evaluate fatigue impact on daily activities
- Monitor sleep patterns
- Assess energy conservation techniques
Evaluate Skin Integrity
- Check for rashes and lesions
- Monitor sun exposure
- Assess wound healing
- Document any new skin changes
Monitor Organ Function
- Assess respiratory status
- Check cardiovascular function
- Monitor renal status
- Evaluate neurological signs
Review Medication Management
- Check medication compliance
- Monitor for side effects
- Assess understanding of medication regimen
- Document any adverse reactions
Nursing Care Plans
Nursing Care Plan 1: Chronic Pain
Nursing Diagnosis Statement:
Chronic Pain related to inflammatory process and tissue damage as evidenced by reported joint pain, fatigue, and decreased activity tolerance.
Related Factors:
- Inflammatory response
- Joint inflammation
- Tissue damage
- Fatigue
- Stress
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Enables proper pain management and treatment adjustment - Administer prescribed medications
Rationale: Controls inflammation and reduces pain - Teach non-pharmacological pain management
Rationale: Provides additional pain relief methods
Desired Outcomes:
- The patient will report decreased pain levels
- The patient will demonstrate improved mobility
- The patient will utilize effective pain management strategies
Nursing Care Plan 2: Fatigue
Nursing Diagnosis Statement:
Fatigue related to chronic disease process and inflammatory response as evidenced by verbalized exhaustion and decreased activity tolerance.
Related Factors:
- Chronic inflammatory process
- Sleep disturbances
- Medication side effects
- Emotional stress
- Disease flares
Nursing Interventions and Rationales:
- Implement energy conservation techniques
Rationale: Maximizes available energy - Establish realistic activity goals
Rationale: Prevents overexertion while maintaining function - Promote adequate rest periods
Rationale: Allows for energy restoration
Desired Outcomes:
- The patient will report improved energy levels
- The patient will demonstrate effective energy conservation
- The patient will maintain balanced activity and rest periods
Nursing Care Plan 3: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to autoimmune response and photosensitivity as evidenced by the presence of rashes and lesions.
Related Factors:
- UV light sensitivity
- Inflammatory response
- Medication side effects
- Compromised immune system
Nursing Interventions and Rationales:
- Assess skin condition daily
Rationale: Enables early detection of changes - Teach sun protection measures
Rationale: Prevents UV-triggered flares - Implement skin care protocol
Rationale: Maintains skin integrity
Desired Outcomes:
- The patient will maintain intact skin
- The patient will demonstrate proper sun protection
- The patient will identify early signs of skin problems
Nursing Care Plan 4: Ineffective Self-Health Management
Nursing Diagnosis Statement:
Ineffective Self-Health Management related to complex treatment regimen as evidenced by verbalized difficulty following the treatment plan.
Related Factors:
- Complex medication schedule
- Limited understanding of disease
- Multiple lifestyle modifications
- Fluctuating symptoms
Nursing Interventions and Rationales:
- Provide disease education
Rationale: Improves understanding and compliance - Teach medication management
Rationale: Ensures proper treatment adherence - Develop a symptom tracking system
Rationale: Helps identify patterns and triggers
Desired Outcomes:
- The patient will demonstrate an understanding of disease management
- The patient will maintain medication compliance
- The patient will effectively track symptoms
Nursing Care Plan 5: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to immunosuppression and chronic disease process as evidenced by compromised immune system.
Related Factors:
- Immunosuppressive therapy
- Chronic disease process
- Altered immune response
- Medication side effects
Nursing Interventions and Rationales:
- Monitor for signs of infection
Rationale: Enables early detection and treatment - Teach infection prevention strategies
Rationale: Reduces infection risk - Promote proper hygiene
Rationale: Minimizes exposure to pathogens
Desired Outcomes:
- The patient will remain free from infection
- The patient will demonstrate proper infection prevention techniques
- The patient will identify early signs of infection
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
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