16.12 Lyme Disease

Lyme disease is an infectious tick-borne illness, most commonly caused by the bacteria Borrelia burgdorferi. Lyme disease normally occurs in the Northeastern and Midwest portions of the United States during late spring, summer, and early fall. It can affect all genders, ages, and races but appears to be more common in Caucasian females.^[1]

Pathophysiology

Lyme disease occurs from an infected tick bite, spreading bacteria from the tick to the client. Symptoms begin to appear within one to two weeks after the bite. After that timeframe, specific strains of the Borrelia bacteria have affinities for different parts of the body. In the case of B. bugdorferi, it usually spreads to the joints.^[2]

Assessment (Recognizing Cues)

Physical Exam

Lyme disease has three different stages called early localized, early disseminated, and late. Each stage has different signs and symptoms, but most clients do not progress past the early localized stage.^[3]

Signs and symptoms specific to the early localized stage are a round, red rash at the site of the tick bite, known as erythema migrans. At times the rash can look like a bullseye, as shown in Figure 16.19.^[4] Other symptoms of this stage are flu-like and consist of the following^[5]:

• Muscle and joint aches
• Fever
• Headache
• Malaise
• Neck stiffness
• Redness and tearing of the eyes

Clients who progress to the second stage of Lyme disease can have numerous erythema migrans lesions, as well as flu-like symptoms; swollen lymph nodes; and issues with the eyes, heart, nervous system, or joints.^[6]

The third stage of Lyme disease occurs months or years after the initial tick bite, typically presenting with arthritis of the knee. Neurological symptoms such as meningitis or Bell’s palsy, cognitive issues, or arrhythmias are also common. Despite treatment, a small percentage of clients may have lingering fatigue and joint and muscle pain.^[7]

Common Laboratory and Diagnostic Tests

When clients present with the classic erythema migrans rash and a known exposure to a tick bite, Lyme disease is diagnosed clinically, and testing may not be required. Blood may be tested for the presence of antibodies to B. burgdorferi, but results may be negative if the client is in the initial stage of infection. For clients in later stages of the disease with cardiac and central nervous system symptoms, an electrocardiogram and brain imaging may be performed.^[8]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with Lyme disease include early treatment and symptom management. Nursing diagnoses for clients with Lyme disease are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with Lyme disease include the following^[9]:

• Impaired skin integrity r/t skin lesions
• Hyperthermia r/t disease process
• Acute pain r/t disease process
• Deficient knowledge r/t tick bite prevention

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with Lyme disease include the following:

• The client’s parents/caregivers will verbalize three methods to prevent tick bites in endemic areas after the teaching session.
• The client’s parents/caregivers will verbalize a description of erythema migrans rash after the teaching session.
• The client will demonstrate reduced pain using a numeric scale, FACES, or FLACC within 24 hours of medical treatment.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Antibiotics are prescribed to treat Lyme disease. Clients older than eight years of age with early, localized disease are prescribed doxycycline. Clients under the age of eight should receive amoxicillin or cefuroxime to avoid the potential for tooth staining caused by tetracycline use in young children. Clients with eye symptoms may require topical steroids as well.^[10]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with Lyme disease, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^{[11],[12],[13],[14]}

Nursing Assessments

• Assess clients for a history of tick exposure or the presence of risk factors such as being outdoors in endemic areas.
• Assess clients for the presence of the erythema migrans rash.
• Assess the client’s vital signs. Temperature may be elevated with Lyme disease.
• Assess for the presence of fatigue and joint aches because these symptoms commonly occur with Lyme disease.

Nursing Actions

• Advocate for a referral to an infectious disease specialist, as indicated.
• Ensure adequate fluid intake for clients with an elevated temperature.
• Administer antibiotics, analgesics, and antipyretics per provider order.
• Encourage clients with extreme fatigue to complete activities at the time when they have the most energy. The client should also be encouraged to rest between periods of activity.

Client Teaching

• Educate the client and their parents/caregivers in endemic areas about early signs of Lyme disease so treatment can begin quickly and complications can be prevented.
• Educate the client and their caregivers on tick bite prevention as outlined in the following box.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.