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Nursing Care Plan (NCP) for Lyme Disease

Nursing Care Plan (NCP) for Lyme Disease

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Study Tools For Nursing Care Plan (NCP) for Lyme Disease

Lyme Disease (Picmonic)
Lyme Disease Pathochart (Cheatsheet)
Example Care Plan_Lyme Disease (Cheatsheet)
Blank Nursing Care Plan_CS (Cheatsheet)

Outline

Lesson Objective for Lyme Disease

  • Understanding Lyme Disease:
    • Gain a comprehensive understanding of Lyme disease, including its etiology, pathophysiology, and the specific microorganism responsible (Borrelia burgdorferi). Identify the primary modes of transmission and geographical areas where Lyme disease is prevalent.
  • Recognition of Clinical Manifestations:
    • Learn to recognize the clinical manifestations and symptoms associated with Lyme disease, such as erythema migrans, flu-like symptoms, joint pain, and neurological complications. Understand the potential for varied presentations in different stages of the disease.
  • Diagnostic Methods:
    • Familiarize oneself with the diagnostic methods for Lyme disease, including serological tests like ELISA and Western blot. Understand the limitations and challenges in diagnosing Lyme disease accurately, especially in the early stages.
  • Treatment Strategies:
    • Explore the recommended treatment modalities for Lyme disease, including antibiotic therapy. Understand the importance of early intervention to prevent complications and chronic sequelae. Learn about the variations in treatment approaches based on the stage of the disease.
  • Prevention and Patient Education:
    • Acquire knowledge about preventive measures, such as avoiding tick exposure, using protective clothing, and conducting thorough tick checks. Understand the importance of patient education in promoting awareness, early detection, and adherence to preventive practices.

Pathophysiology of Lyme Disease

  • Bacterial Transmission:
    • Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi, primarily transmitted through the bite of infected black-legged ticks (Ixodes scapularis or Ixodes pacificus).
  • Multi-Stage Infection:
    • The infection progresses through multiple stages: localized infection, early disseminated infection, and late persistent infection. Each stage presents distinct clinical features and complications.
  • Localized Infection (Early Stage):
    • Following a tick bite, an erythema migrans (EM) rash may appear at the site of infection, indicating local spread. This stage is often accompanied by flu-like symptoms, such as fever, fatigue, and muscle aches.
  • Early Disseminated Infection:
    • B. burgdorferi can disseminate through the bloodstream, leading to more widespread symptoms. Neurological, cardiac, and musculoskeletal manifestations may occur. Multiple EM rashes, facial palsy, and heart conduction abnormalities are possible.
  • Late Persistent Infection:
    • If untreated, Lyme disease can progress to chronic stages, with persistent symptoms affecting joints, the nervous system, and other organs. Chronic Lyme arthritis and neurological complications, such as cognitive impairment, may develop.

Etiology of Lyme Disease

 

  • Bacterial Cause:
    • Lyme disease is caused by the spirochete bacterium Borrelia burgdorferi, with Borrelia mayonii and Borrelia afzelii also implicated in certain regions. These bacteria are transmitted to humans through the bite of infected black-legged ticks.
  • Vector Transmission:
    • Ticks of the Ixodes genus, particularly Ixodes scapularis (commonly known as the black-legged or deer tick) in the eastern United States and Ixodes pacificus in the western United States, are the primary vectors of Lyme disease.
  • Reservoir Hosts:
    • Small mammals, particularly rodents like mice and birds, serve as reservoir hosts for the Lyme disease bacterium. Ticks acquire the infection when feeding on these reservoir hosts.
  • Geographic Distribution:
    • Lyme disease is most prevalent in certain geographic regions, including wooded and grassy areas where ticks carrying the bacterium are abundant. It is more commonly reported in the northeastern, north-central, and Pacific coastal regions of the United States.
  • Seasonal Risk:
    • The risk of Lyme disease transmission is highest during the warmer months (spring and summer) when ticks are most active and people engage in outdoor activities. Timely removal of attached ticks reduces the risk of infection.

Desired Outcome of Nursing Care for Lyme Disease

 

  • Resolution of Symptoms:
    • Alleviation of presenting symptoms such as erythema migrans (characteristic rash), flu-like symptoms, joint pain, and neurological manifestations, leading to the restoration of the patient’s overall well-being.
  • Prevention of Complications:
    • Early detection and treatment to prevent the progression of Lyme disease and reduce the risk of complications, including disseminated infection, cardiac involvement, and neurological sequelae.
  • Negative Serology:
    • Achieving negative or significantly reduced levels of specific antibodies against Borrelia burgdorferi in follow-up serological tests, indicating a successful response to treatment and reduced bacterial load.
  • Restoration of Function:
    • Regaining normal function and activities of daily living by managing and resolving symptoms, particularly those affecting joints, muscles, and neurological function.
  • Education and Prevention:
    • Empowering the patient with knowledge about Lyme disease, its prevention, and the importance of early intervention. This includes educating individuals about tick avoidance strategies, proper tick removal, and the significance of seeking medical attention if symptoms develop after a tick bite.

Lyme Disease Nursing Care Plan

 

Subjective Data:

Initial Symptoms

  • Headache
  • Fatigue
  • Muscle / joint pain

Advanced Symptoms:

  • Neck stiffness
  • Nerve pain
  • Short-term memory loss
  • Dizziness
  • Shortness of breath

Objective Data:

Initial Symptoms

  • Bullseye rash (erythema migrans)
  • Fever / chills
  • Swollen lymph nodes

Advanced Symptoms:

  • Facial palsy
  • Inflammation of the brain / spinal cord
  • Palpitations and irregular heartbeats

Nursing Assessment for Lyme Disease

 

  • Patient History:
    • Thoroughly document the patient’s history, including recent outdoor activities, exposure to wooded or grassy areas, and any known tick bites.
  • Symptom Assessment:
    • Evaluate and document the presence and severity of symptoms, such as erythema migrans (bull’s-eye rash), fever, fatigue, headache, muscle and joint pain, and neurological symptoms (e.g., Bell’s palsy).
  • Skin Examination:
    • Perform a comprehensive examination of the skin to identify and document the presence of erythema migrans or other skin manifestations associated with Lyme disease.
  • Joint Assessment:
    • Assess joints for signs of inflammation, pain, and limitation of movement. Focus on commonly affected joints, such as the knees.
  • Neurological Assessment:
    • Conduct a neurological assessment, including cranial nerve examination, to identify any neurological deficits or abnormalities, especially if the patient presents with symptoms like facial paralysis or cognitive changes.
  • Laboratory Tests:
    • Coordinate with the healthcare team to obtain laboratory tests, including serological tests for Lyme antibodies (e.g., enzyme immunoassay and Western blot), to confirm the diagnosis and monitor treatment response.
  • Psychosocial Assessment:
    • Evaluate the patient’s emotional well-being, addressing concerns, fears, or anxieties related to the diagnosis and potential complications. Identify any impact on daily activities and relationships.
  • Educational Assessment:
    • Assess the patient’s knowledge about Lyme disease, its transmission, and preventive measures. Identify areas where education is needed and provide information about proper tick removal and the importance of early medical intervention.

 

Implementation for Lyme Disease

 

  • Administer Antibiotic Therapy:
    • Initiate and monitor the administration of prescribed antibiotics, typically doxycycline, amoxicillin, or cefuroxime, to target the causative bacterium (Borrelia burgdorferi). Ensure adherence to the prescribed dosage and duration.
  • Pain Management:
    • Provide pain relief measures to address joint and muscle pain associated with Lyme disease. Administer analgesics as ordered, and assess the effectiveness of pain management strategies.
  • Educate on Prevention:
    • Educate the patient on preventive measures, including avoiding tick-infested areas, using insect repellent, wearing protective clothing, and conducting thorough tick checks after outdoor activities.
  • Joint Support and Rehabilitation:
    • Collaborate with physical therapy services to develop a joint support and rehabilitation plan. Assist the patient in maintaining joint function and preventing complications associated with Lyme arthritis.
  • Monitor and Manage Symptoms:
    • Regularly assess and monitor the patient’s symptoms, including skin manifestations, joint pain, and neurological symptoms. Implement interventions to manage specific symptoms, such as applying topical treatments for skin manifestations or providing supportive care for neurological symptoms.

Nursing Interventions and Rationales

 

  • Assess skin for rash

 

Classic, hallmark symptom of Lyme Disease is the bullseye rash at the site of the tick bite that is non-painful and not itchy. Other areas may develop rash as the disease progresses if not treated.

 

  • Monitor vital signs

 

As the disease progresses, it may affect organ systems. Monitor for changes in blood pressure, heart rate and elevation of temperature.

 

  • Perform 12-lead ECG

 

Lyme carditis is a complication of Lyme disease and may cause cardiac dysrhythmias and chest pains.

 

  • Apply cool compresses to swollen and painful joints

 

Patients will commonly complain of joint swelling and pain, especially of the knees, which are warm to touch. Cool compresses help relieve pain and swelling.

 

  • Provide and promote calm, low stress environment

 

Advanced Lyme disease may cause neurological disorders such as memory loss and irritability. Provide low stress environment to help manage neurological symptoms.

 

  • Assist with ROM exercises; AROM and PROM

 

Encourage mobility and loosen painful joints

 

  • Administer medications appropriately

 

Antibiotics are given as soon as the disease is detected to treat Lyme disease. Other medications may be given to treat symptoms of disease such as analgesics, NSAIDs to reduce inflammation, and anti-emetics for gastric involvement.

 

  • Educate patients and family members on ways to reduce risk of Lyme disease

 

Prevent re-exposure and further complications

Evaluation for Lyme Disease

 

  • Resolution of Symptoms:
    • Evaluate the extent to which Lyme disease symptoms have resolved or improved. This includes assessing the disappearance of skin manifestations, reduction in joint pain, and resolution of neurological symptoms.
  • Laboratory Tests:
    • Monitor laboratory results, especially serological tests for Lyme disease. Assess whether titers have decreased or become negative, indicating a response to treatment and a reduction in the presence of the causative bacterium.
  • Functional Status:
    • Evaluate the patient’s overall functional status, including their ability to perform daily activities and engage in physical and social activities. Improvement in functional status indicates a positive response to treatment.
  • Patient Education and Compliance:
    • Assess the patient’s understanding of preventive measures and their compliance with recommendations. Evaluate whether the patient has adopted practices to reduce the risk of future tick exposure and Lyme disease recurrence.
  • Quality of Life:
    • Consider the impact of Lyme disease and its treatment on the patient’s quality of life. Assess psychological well-being, the ability to participate in work or recreational activities, and overall satisfaction with the treatment outcomes.

References

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Transcript

Today, we are talking about Lyme disease. Okay. I’m sure many of you have heard of Lyme disease, but Lyme disease is a tick-borne illness that is caused by the bacteria Borrelia burgdorferi, and it happens after you are bitten by an infected tick. The disease can show symptoms for 30 days after. The main characterization, the symptoms are rash and they can continue for months or a year. Following the initial onset, severe cases can lead to organ dysfunction, such as heart and liver involvement. Some of the nursing considerations that we want to do, we want to assess for a bullseye rash. I have a picture of that for you, but we want to assess for a bullseye rash. That is the hallmark sign that you have been infected with Lyme disease. We also want to assess the patient’s neurological status and heart sounds. We want to take a list of the heart sounds, and we want to monitor the heart with ECG for arrhythmias. The desired outcomes for the patient to be infection-free. 

We want to manage and reduce the pain and inflammation. We want to make sure the patient regains optimal mobility, and we want to prevent complications. So this right here is a photo of a bullseye rash. So you see it has the, the red ring around, and then it has a little bullseye. It looks just like a bullseye, but just remember bullseye Lyme disease. Okay. Because that is going to be on your NCLEX. Trust me. Some of the subjective data; there are typically two phases. When you think of Lyme disease, there is going to be the initial set of symptoms and there as the condition progresses. And then that’s what we get into the advanced symptoms. So some initial symptoms for Lyme disease include headache. We are going to have some fatigue. We are going to have some muscle and joint pain, and we’re going to also  advance to some of the advanced symptoms. 

So these are all subjective things. So we’re going to have some nerve pain; once we get nerve involvement, we’re pretty far along. So we’re going to have some nerve pain. We’re going to have some short term memory loss, dizziness, shortness of breath. Some of the things that we’re going to observe, some of the objective data. Initially, we are going to see the bullseye rash. So that is that red ring that looks like a bullseye. The patient is also going to have a fever and chills and swollen lymph nodes. Once we get advanced, there’s going to be some facial palsy. 

So, you know, that’s the drooping of the face. There’s also going to be some inflammation of the brain or spinal cord as well as palpitations or irregular heartbeat. So as nurses, we are going to assess the skin; we’re going to assess the skin for a rash. The classic hallmark symptom of Lyme disease is that bullseye rash. So,we want to assess for that. Other areas may develop a rash as disease progresses, if not treated. So that could also be a part of the advanced symptoms as well. We’re gonna perform a 12 lead EKG or ECG for myocarditis, which is the arrhythmias that occur. It’s just a complication of Lyme disease. So we do not want those dysrhythmias because those can be fatal if untreated. Okay, we’re going to apply cool compresses. You know, everything does not have to be pharmacological. 

We don’t always have to use medicine. We can apply warm compresses because those joints are going to be red and inflamed and tender. So we want to apply some whole compresses just to help relieve some of that pain and some of that swelling. Okay, we’re going to administer the medications appropriately. So antibiotics are to be given as soon as the disease is detected, because the quicker we can start on treating it the quicker we can add those symptoms. And hopefully we can get over that hump of Lyme disease. Also, we want to think about the pain. So we want to use things like analgesics. We want to use NSAIDs to reduce the inflammation at times, medications for any gastric involvement, because these patients also tend to have some nausea and vomiting. 

We’re going to educate the family and the patient; we’re going to educate them on how to reduce the risk of Lyme disease, because it is a tick borne illness. We want to make sure that we can prevent re-exposure so that we can avoid those further complications. So, you know, things like wearing long pants and long socks when you’re in the woods, tucking your pants into your socks, long sleeve shirts, and just covering your body, and also assessing your body, checking your body for ticks as well. Okay. And the final thing is something that we should do if we want to assess the patient with range of motion. Okay, we want to assist with range of motion, because again, those joints are stiff. Those joints are inflamed. So the patient is not going to want to move, but we go, we’re going to need to get those joints moving to kind of get that blood flow working as we work on that inflammation. 

We’ll encourage mobility and loosen those painful joints. Some key points, Lyme disease is caused by ticks. They are caused specifically by the deer tick. Some subjective and objective data that we want to just keep in mind are headache, nerve pain, dizziness, and fatigue. Those are some of the most common things that patients are going to present with. We’re going to look for that bullseye rash. That’s the hallmark sign. We’re going to look with the EKG for irregular heartbeats. We’re going to look for some facial palsy. Remember the facial palsy is going to be something that is further down the bullseye rash. That is our hallmark sign. That is the number one thing we’re going to look for. And remember that bullseye rash is not itchy. So we’re going to want to do a good visual assessment of the skin. We’re also going to do some cardiac monitoring, the 12 lead for dysrhythmias. We’re going to do frequent vital signs. Okay. Endocarditis is a complication that can cause that fatal arrhythmia. Okay. We love you guys. Go out and be your best self today. And, as always, happy nursing.

 

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