Lyme disease typically begins in summer or early fall and develops in three stages with varying, progressive symptoms over weeks and months if untreated. The most frequent carrier of the disease is the deer tick, a small insect the size of a poppy seed. The deer tick is predominantly found in the New England and mid-Atlantic states,Wisconsin, Minnesota, and northern California, although cases of Lyme disease have been documented in 48 states. Severe long-term effects occur in fewer than 10% of untreated cases. Complications include pericarditis and myocarditis, cardiac dysrhythmias, encephalitis, peripheral neuropathies, and arthritis. Incubation lasts 7 to 10 days, but diagnosis generally must wait for 4 to 6 weeks after the patient is bitten by a tick in order to make laboratory tests reliable.
Lyme disease is caused by a spirochete, Borrelia burgdorferi. This organism can be transmitted through the saliva of the tick while it is ingesting blood from a host. Not all ticks carry this spirochete, and all bites from infected ticks do not lead to Lyme disease. Burning a tick off or smothering it with petroleum jelly potentiates the spirochete injection via reflux regurgitation.
Nursing care plan assessment and physical examination
Note that this disease progresses in stages, each having its own unique symptoms. The first stage involves skin invasion. A characteristic “bull’s eye” rash (erythema migrans) and flulike symptoms may occur within days to weeks of the tick bite. During the second stage, the nerve tissue is invaded, and the patient experiences neurological symptoms and possibly cardiac problems. The most common neurological complications are Bell’s palsy and aseptic Lyme meningitis, which can progress to encephalitis. Without treatment at this stage, 8% of patients develop cardiac complications such as heart block, pericarditis, congestive heart failure, dizziness, shortness of breath, and palpitations. Final progression of the untreated disease results in arthritis, which sometimes becomes chronic. Tendons, bursae, and joints (most commonly the knees) may subsequently become infected and result in the arthritic symptoms characteristic of stage three. Obtain a thorough history regarding the patient’s recall of a tick bite within the past 3 to 30 days and recall of exposure to geographic “hot spots.” Note that there is a seasonal component to exposure (May to August). Question the patient carefully about presence of malaise, muscle and joint pain, stiff neck, headache, and fatigue, all of which are early symptoms.
Inspect the skin for the characteristic rash, a reddened expanding ring with a lighter center. The rash may be warm to touch, but it is usually painless and may grow to be inches in diameter. Inspect the face for any signs of paralysis; determine if the patient can open and close the eyes and mouth symmetrically. Determine the patient’s temperature. Auscultate the patient’s heart rate for irregularity and the presence of tachycardia. Progressive symptoms in untreated patients involve neurological and musculoskeletal symptoms. Perform a complete neurological examination. Assess the range of motion of the neck and other joints, and determine the patient’s muscle strength.
Anxiety of the unknown—both the fear of disease progression and the fear of the potential for reinfection—contributes to the psychological effect of this disease. Patients may be frustrated with experiencing memory loss; determine the family’s understanding and ability to support the patient with an altered mental status.
Nursing care plan primary nursing diagnosis: Anxiety related to knowledge deficit of disease progression, treatment, and prevention.
Nursing care plan intervention and treatment plan
Oral antibiotics are usually started as early as possible. Tetracycline is the primary choice, but doxycycline, penicillin, and ceftriaxone are also given. Children are usually treated with oral penicillin. Fever is treated with antipyretics and sometimes, cooling blankets. Research is being done on using the protein Osp A from the Lyme spirochete as a potential vaccination for this disease. Surprisingly, Osp A vaccination in mice has kept them free from Lyme disease after infected tick bites, but it also killed the spirochete that was present in the ticks who bit the vaccinated mice. Use of this vaccine might be considered in plant and water supplies to help stop the spread of Lyme disease.
Nursing care varies, depending on the disease stage. Manage fever with cool sponge baths and limited bedding. Maintain a cool temperature in the environment if possible. Manage fatigue with promotion of rest and comfort. Ice bags are effective for headache. Arthralgia may require immobilization of the painful joint, warm moist applications, and other nonpharmacologic measures to control pain. Assist the patient with range-of-motion exercises and activities to strengthen muscles and joints, being careful not to overexert the patient.
Provide emotional support to patients who are experiencing memory loss and confusion. Determine the patient’s chance for injury and plan accordingly by instituting safety measures. Frequently reorient the patient to her or his surroundings. Encourage the patient to share any concerns about her or his mental status. Explain the reason for the mental status changes to the patient and significant others, and answer any questions about the long-range complications of the disease.
Nursing care plan discharge and home health care guidelines
Teach the patient strategies to prevent tick bites by wearing protective clothing, such as long sleeves and long pants (pant legs should also be tucked inside of socks) in at-risk areas, fullcover shoes (not sandals), and light-colored clothing to help make identification of the tiny dark ticks easier. Use chemical repellents such as DEET, but note they may cause respiratory distress if too much is used, especially in children. Stay on cleared paths and avoid wandering through grass and woods. Inspect the body daily with attention to the prime locations for bites: back, axilla, neck, ankle, groin, scalp, and back of the knees. Wash and dry exposed clothing for at least 30 minutes to kill concealed ticks. Inspect pets as well, not only for carrying ticks into the house but also because Lyme disease is a prime cause of animal arthritis. If a tick is attached to the skin, remove it carefully to avoid causing it to regurgitate saliva and spirochetes into the host. Use tweezers close to the skin to pull the head or jaw out of the skin. Cleanse the site with antiseptic agent. Do not try to burn off the tick or to smother it with kerosene or petroleum jelly. Emphasize that the patient should finish the entire course of antibiotics, even if he or she is asymptomatic. Inform the physician of recurrent or progressive symptoms for consideration of reinfection.