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NCLEX RN Practice Question # 484

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Autoimmune Disease (NCLEX Review)

Description

  • Body is unable to recognize its own cells as a part of itself.
  • Autoimmune disease can affect collagenous tissue.

Systemic lupus erythematosus (SLE)

Description

  • Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail
  • Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs.
  • The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura.
  • No cure for the disease is known but remissions are frequently experienced by clients who manage their care well.

Causes

  • The cause of SLE is unknown, but is believed to be a defect in immunological mechanisms, with a genetic origin.
  • Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy.
  • Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the skin rash that occurs in lupus.

Assessment

  • Assess for precipitating factors.
  • Erythema butterfly or rash of the face (malar)
  • Dry, scaly, raised rash on the face or upper body
  • Fever
  • Weakness, malaise, and fatigue
  • Anorexia
  • Weight loss
  • Photosensitivity
  • Joint pain
  • Erythema of the palms
  • Anemia
  • Positive antinuclear antibody (ANA) test and lupus erythematosus (LE) preparation
  • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level

Interventions

  • Monitor skin integrity and provide frequent
  • Instruct the client to clean the skin with a mild soap, avoiding harsh and perfume substances.
  • Assist with the use of ointments and creams for the rash as prescribed.
  • Identify factors contributing to fatigue.
  • Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs.
  • Provide a high-vitamin and high-iron diet.
  • Provide a high-protein diet if there is no evidence of kidney disease.
  • Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise.
  • Administer topical or systemic corticosteroids, salicylates, and nonsteroidal antiinflammatory drugs as prescribed for pain and inflammation.
  • Administer medications to decrease the
  • inflammatory response as prescribed.
  • Instruct the client to avoid exposure to sunlight and ultraviolet light.
  • Monitor for proteinuria and red cell casts in the urine.
  • Monitor for bruising, bleeding, and injury.
  • Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs.
  • Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis.
  • Note that lupus nephritis occurs early in the disease process.
  • Provide supportive therapy as major organs become affected.
  • Provide emotional support and encourage the client to verbalize feelings.
  • Provide information regarding support groups and encourage the use of community resources. For the client with SLE,

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