A patient with a history of systemic lupus erythematosus (SLE) presents with respiratory distress, worsening renal function, and signs of a lupus flare. Following initial interventions, which nursing action is most critical to prioritize in the immediate management of this patient?

D) Adjust the oxygen delivery system to ensure adequate tissue oxygenation.

A) Monitor the patient's neurological status for changes in mental alertness.

B) Administer additional diuretics to reduce peripheral edema.

C) Prepare the patient for an urgent renal biopsy to confirm lupus nephritis.

D) Adjust the oxygen delivery system to ensure adequate tissue oxygenation.

A patient with systemic lupus erythematosus (SLE) presents in the emergency department with respiratory distress, a malar rash, and worsening renal function. Given the patient's current condition, which nursing intervention is most critical to prioritize to prevent immediate life-threatening complications?

B) Initiate supplemental oxygen therapy to maintain adequate oxygenation and prevent respiratory failure.

A) Administer high-dose intravenous methylprednisolone to reduce inflammation and control the lupus flare.

B) Initiate supplemental oxygen therapy to maintain adequate oxygenation and prevent respiratory failure.

C) Prepare the patient for a renal biopsy to determine the extent of lupus nephritis.

D) Monitor cardiac status closely to detect signs of cardiac tamponade and initiate appropriate interventions.

A patient with systemic lupus erythematosus (SLE) has developed acute respiratory distress syndrome (ARDS) secondary to lupus pneumonitis and is exhibiting signs of early cardiac tamponade. The healthcare team is preparing for potential intubation and mechanical ventilation, as well as considering pericardiocentesis. What should be the nurse's priority action to prepare for these interventions?

B) Prepare the patient for an emergent pericardiocentesis to alleviate cardiac tamponade.

A) Administer a dose of IV diuretics to manage fluid overload.

B) Prepare the patient for an emergent pericardiocentesis to alleviate cardiac tamponade.

C) Arrange for the necessary equipment and medications for intubation and mechanical ventilation.

D) Monitor the patient's vital signs closely and report any changes to the healthcare provider.

A 32-year-old female patient with a history of systemic lupus erythematosus is admitted with lupus pneumonitis and is now exhibiting signs of acute respiratory distress syndrome (ARDS) and early cardiac tamponade. Despite aggressive treatment with high-dose intravenous methylprednisolone, her condition is deteriorating. As the nurse coordinating her care, which immediate intervention is the priority to address her current hemodynamic instability?

B) Prepare for emergency pericardiocentesis to relieve cardiac tamponade.

A) Initiate continuous renal replacement therapy (CRRT) to manage metabolic acidosis.

B) Prepare for emergency pericardiocentesis to relieve cardiac tamponade.

C) Start vasopressor therapy to maintain blood pressure and improve perfusion.

D) Proceed with endotracheal intubation and mechanical ventilation to stabilize respiration.

A nurse is caring for a patient with systemic lupus erythematosus (SLE) who has been intubated and is on mechanical ventilation for ARDS secondary to lupus pneumonitis. After a pericardiocentesis, the patient's renal function declines, indicating acute kidney injury. Which nursing intervention is most critical at this time to prevent further complications?

C) Monitor the patient closely for signs of infection and sepsis.

A) Increase the patient's fluid intake to enhance renal perfusion.

B) Collaborate with the nephrology team to initiate renal replacement therapy.

C) Monitor the patient closely for signs of infection and sepsis.

D) Adjust the ventilator settings to improve oxygenation and lower FiO2.

A patient diagnosed with ARDS secondary to lupus pneumonitis is on mechanical ventilation. Following intubation and pericardiocentesis, she shows a temporary stabilization but develops acute kidney injury (AKI). As the nurse coordinating care, which intervention should be prioritized to address the patient's current clinical challenges?

C) Collaborate with the interdisciplinary team to reassess and potentially modify the patient's immunosuppressive therapy to prevent further organ damage.

A) Initiate continuous renal replacement therapy (CRRT) to manage fluid overload and electrolyte imbalances.

B) Adjust the ventilator settings to further improve oxygenation and decrease the risk of ventilator-associated lung injury.

C) Collaborate with the interdisciplinary team to reassess and potentially modify the patient's immunosuppressive therapy to prevent further organ damage.

D) Administer intravenous antibiotics preemptively to reduce the risk of sepsis following invasive procedures.

A 35-year-old female patient with a history of lupus presents with acute kidney injury, hypotension, new-onset arrhythmias, and signs of possible infection. As the nurse, what is the priority intervention to initiate in collaboration with the healthcare team?

B) Prepare the patient for urgent renal replacement therapy.

C) Initiate intravenous fluids to manage hypotension and improve perfusion.

D) Monitor cardiac rhythm closely and prepare for possible antiarrhythmic therapy.

A patient with lupus presents with acute kidney injury, new-onset arrhythmias, decreased hemoglobin, elevated white blood cell count, and fever. As the nurse, which intervention is the highest priority in managing this patient's condition?

B) Administer broad-spectrum antibiotics to treat potential infection.

A) Prepare for immediate hemodialysis to address acute kidney injury.

B) Administer broad-spectrum antibiotics to treat potential infection.

C) Initiate fluid resuscitation to manage low blood pressure.

D) Consult the hematology team for evaluation of possible hemolytic anemia.

A patient in the ICU is undergoing continuous renal replacement therapy (CRRT) for acute kidney injury and fluid overload. The nurse notes the patient's calcium level has dropped to 7.5 mg/dL during the therapy. Which immediate nursing action is most appropriate to prevent potential complications associated with hypocalcemia?

A) Administer calcium gluconate as prescribed and monitor for signs of tetany.

B) Increase the patient's fluid intake to dilute the calcium level.

C) Notify the nephrologist to discontinue CRRT immediately.

D) Encourage the patient to ambulate to improve blood circulation.

A patient with systemic lupus erythematosus (SLE) is experiencing hemodynamic instability, respiratory distress, and signs of disseminated intravascular coagulation (DIC). The patient is currently on continuous renal replacement therapy (CRRT) and broad-spectrum antibiotics. Which of the following nursing interventions is the most critical to prioritize at this time?

D) Monitoring for and addressing potential bleeding complications associated with DIC.

A) Administering calcium gluconate to correct hypocalcemia and prevent cardiac complications.

B) Increasing the rate of vasopressor infusion to stabilize blood pressure and improve hemodynamic status.

C) Initiating thermal measures to manage persistent fever and reduce metabolic demand.

D) Monitoring for and addressing potential bleeding complications associated with DIC.

Lupus - Nursing Case Study

Pathophysiology

• Primary mechanism: Autoimmune dysregulation leads to the production of autoantibodies, particularly antinuclear antibodies (ANAs), which target and damage self-tissues, triggering inflammatory responses throughout the body.

• Secondary mechanism: Immune complex deposition occurs when these autoantibodies form complexes with antigens, depositing in tissues such as the kidneys, skin, and joints. This deposition activates the complement system, further exacerbating inflammation and tissue injury.

• Key complication: Lupus nephritis is a severe complication resulting from immune complex deposition in the glomeruli, leading to impaired renal function and potentially progressing to end-stage renal disease if untreated.

Patient Profile

Demographics:

34-year-old female, software engineer

History:

• Key past medical history: Diagnosed with Systemic Lupus Erythematosus (SLE) at age 28, history of lupus nephritis and pericarditis

• Current medications: Prednisone, Hydroxychloroquine, Mycophenolate mofetil, Lisinopril, Atenolol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe joint pain, difficulty breathing

• Key symptoms: Fatigue, facial rash, edema in lower extremities, chest pain, fever

• Vital signs: Blood pressure 160/100 mmHg, heart rate 120 bpm, respiratory rate 28 breaths per minute, temperature 39.2°C (102.6°F), oxygen saturation 88% on room air

Section 1

As the initial assessment progresses in the emergency department, the clinical team notes several alarming findings that require immediate attention. The patient's respiratory distress is evident, with labored breathing and use of accessory muscles. Auscultation of the lungs reveals diffuse crackles, suggesting pulmonary involvement, potentially from lupus-related pleuritis or early signs of acute lupus pneumonitis. Cardiac assessment highlights a pericardial friction rub, consistent with her history of pericarditis, and raises concerns about potential cardiac tamponade. The patient's skin exhibits a pronounced malar rash, and oral mucosal ulcers are present, both indicative of active lupus flare. Her extremities show significant pitting edema, raising the suspicion of worsening renal function.

Laboratory investigations reveal a concerning array of abnormalities. Serum creatinine has risen to 2.8 mg/dL from a baseline of 1.2 mg/dL, indicating an acute deterioration in renal function, likely exacerbated by lupus nephritis. Urinalysis shows 4+ proteinuria and active sediment with red blood cell casts, confirming the suspicion of a renal lupus flare. Blood tests show elevated anti-dsDNA antibodies and low complement levels (C3 and C4), markers consistent with heightened lupus activity. Additionally, an arterial blood gas analysis indicates metabolic acidosis with a pH of 7.30, HCO3- of 18 mEq/L, and a PaO2 of 65 mmHg, further complicating her respiratory status and necessitating supplemental oxygen.

Recognizing the critical nature of her condition, the healthcare team initiates aggressive interventions, including high-dose intravenous methylprednisolone to control the lupus flare, supplemental oxygen to address hypoxemia, and a diuretic to manage fluid overload. However, the patient's condition remains precarious, necessitating close monitoring in the intensive care unit. The next steps involve a multidisciplinary approach, including nephrology for possible renal biopsy and rheumatology for comprehensive lupus management, while preparing for potential complications such as acute respiratory failure or cardiac complications that could arise from her severe autoimmune activity.

Section 2

As the patient's situation evolves, the healthcare team notes a troubling change in her status approximately 24 hours post-admission. Despite the administration of high-dose intravenous methylprednisolone, her respiratory condition has deteriorated further. The patient exhibits increasing respiratory distress, characterized by a respiratory rate climbing to 32 breaths per minute and a drop in oxygen saturation to 88% on high-flow oxygen therapy. An urgent repeat arterial blood gas analysis reveals worsening hypoxemia with a PaO2 of 55 mmHg and an escalating metabolic acidosis, as evidenced by a pH of 7.25 and HCO3- of 15 mEq/L. Given these findings, the team considers the development of acute respiratory distress syndrome (ARDS) secondary to lupus pneumonitis and prepares for potential intubation and mechanical ventilation to stabilize her breathing.

Concurrently, the patient's cardiac assessment reveals new concerns. An echocardiogram performed to evaluate the pericardial friction rub indicates the presence of a moderate pericardial effusion with signs of early cardiac tamponade, as evidenced by diastolic collapse of the right atrium and a drop in her blood pressure to 90/60 mmHg with noted pulsus paradoxus. The cardiology team is consulted urgently to assess the need for pericardiocentesis to prevent further hemodynamic compromise. These developments necessitate an urgent reevaluation of her treatment plan, considering both her respiratory and cardiac deterioration.

This unfolding scenario demands advanced clinical reasoning and decision-making. The multidisciplinary team must weigh the risks and benefits of continuing aggressive immunosuppressive therapy against the need for immediate interventions to manage her acute complications. The decision to proceed with invasive procedures such as pericardiocentesis and mechanical ventilation highlights the complexity of her condition and underscores the importance of a coordinated approach to care. As the team navigates these challenges, they remain vigilant for potential complications, including sepsis or multi-organ dysfunction, which could further complicate her already precarious state.

Section 3

As the healthcare team proceeds with the management plan, they prioritize the most immediate threats to the patient's stability. The decision is made to proceed with both intubation and pericardiocentesis. Following the successful intubation, the patient is placed on mechanical ventilation with settings optimized to manage her ARDS secondary to lupus pneumonitis. Despite initial improvement in her oxygenation with a PaO2 rising to 75 mmHg on an FiO2 of 60%, her overall clinical picture remains fragile.

During the pericardiocentesis procedure, approximately 200 mL of serosanguinous fluid is aspirated, resulting in a temporary stabilization of her hemodynamics. Post-procedure vitals show a slight improvement in blood pressure to 100/70 mmHg with a reduction in pulsus paradoxus. However, the patient's renal function begins to decline, as evidenced by a rise in serum creatinine from 0.9 mg/dL to 1.8 mg/dL, and her urine output decreases to 20 mL/hr, suggesting the onset of acute kidney injury potentially exacerbated by lupus nephritis and systemic inflammation.

In light of these developments, the multidisciplinary team convenes to reassess the treatment strategy, balancing the need for continued immunosuppression with the risk of further organ dysfunction. The nephrology team is consulted to evaluate the potential role of renal replacement therapy, while infectious disease specialists are on high alert for signs of sepsis, given the recent invasive procedures and the patient's immunosuppressed state. This complex scenario demands vigilant monitoring and fine-tuning of the therapeutic approach to navigate the precarious balance between aggressive treatment and the mitigation of further complications.

Section 4

As the healthcare team continues to manage the complexities of the patient's condition, a significant change in her status prompts immediate attention. Overnight, the patient's urine output further declines to 10 mL/hr, and her serum creatinine level escalates to 2.5 mg/dL, confirming the progression of acute kidney injury. Concurrently, her blood pressure drops to 90/60 mmHg despite fluid resuscitation efforts, indicating potential worsening of her hemodynamic status. The patient's cardiac monitor reveals new-onset arrhythmias, with episodes of premature ventricular contractions that increase in frequency.

Laboratory results return showing a significant drop in her hemoglobin level from 12 g/dL to 9 g/dL, raising concerns about possible internal bleeding or hemolysis, which could be exacerbated by her underlying lupus. Her white blood cell count is elevated at 18,000/mm³, and her C-reactive protein levels have spiked, suggesting heightened inflammatory activity or an infectious process. Despite the initial stabilization post-pericardiocentesis, the patient now exhibits a low-grade fever of 100.5°F, further complicating the clinical picture and fueling suspicion of an infectious etiology.

Faced with these developments, the healthcare team must employ advanced clinical judgment to prioritize interventions. The nephrology team deliberates on initiating renal replacement therapy, weighing the risks and benefits in the context of her fluctuating hemodynamics and potential sepsis. Infectious disease specialists recommend initiating broad-spectrum antibiotics while awaiting culture results, given the high risk of infection. The team also considers the possibility of hematologic involvement, necessitating further evaluation for hemolytic anemia or other lupus-related complications. Each decision requires careful consideration of the potential impact on the patient's multifaceted condition, underscoring the critical need for coordinated care and dynamic problem-solving.

Section 5

As the healthcare team continues to navigate the complexities of the patient's condition, a sudden change in her status demands immediate action. The patient's hemodynamic instability worsens, with her blood pressure plummeting to 85/55 mmHg despite aggressive fluid management and vasopressor support. Her heart rate surges to 130 beats per minute, suggesting compensatory tachycardia. Concurrently, she begins to exhibit signs of respiratory distress, with an increased respiratory rate of 28 breaths per minute and decreased oxygen saturation levels at 88% on room air, necessitating supplemental oxygen.

The nephrology team decides to initiate continuous renal replacement therapy (CRRT) in light of her declining renal function and fluid overload, aiming to stabilize her electrolytes and manage acidosis. During the procedure, the patient's potassium level, initially elevated at 6.2 mEq/L, begins to normalize, reducing the risk of life-threatening arrhythmias. However, her calcium level drops to 7.5 mg/dL, prompting the team to administer calcium gluconate to address potential complications such as tetany or further cardiac disturbances.

Meanwhile, the infectious disease specialists commence broad-spectrum antibiotic therapy, targeting both gram-positive and gram-negative pathogens, as they await culture results. The patient's fever persists, and her skin shows new petechial rashes, raising concerns about disseminated intravascular coagulation (DIC) as a new complication. The hematology team is consulted, and they begin evaluating the possibility of microangiopathic hemolytic anemia, a known lupus-related complication. This multidisciplinary approach highlights the necessity of comprehensive and adaptive clinical reasoning to address the evolving challenges in the patient's care, emphasizing the need for constant vigilance and reassessment in managing such a precarious health state.