Introduction Lyme disease is the most common tick-borne disease in North America and Europe. Lyme disease is steadily increasing in the United States and the majorities of health care providers are unfamiliar with the disease; primarily because of its complexity and as a result lack the clinical skills necessary to provide comprehensive care to infected patients.
The purpose of this paper is to give an overview of the health problem of the disease, epidemiology, incidence and prevalence, pathophysiology, application of the nursing theory, and present the case study with an appropriate plan of care. Overview of Health Problem Lyme disease is the leading cause of vector-borne infections in the U. S. with about 15,000 cases reported annually (Bacon, Kugeler, & Mead, 2008). In order to provide comprehensive care the healthcare provider must recognize the progression of the disease as well as the associated symptoms.
According to Ignatavicius &Workman (2010) Lyme disease progresses through three stages: * Localized stage 1 (early stage)- symptoms begin in three to thirty days of the tick bite and the patient presents with flu-like symptoms, muscle and joint pain and stiffness, and “erythema migrans”, an oval or round, flat or slightly raised rash resembling a “bull’s eye”. * Stage 2 (early disseminated stage)-symptoms occur two to twelve weeks after the tick bite.
During this phase the patient may develop cardiac symptoms such as carditis, palpitations, dizziness, or dyspnea, as well as central nervous system anomalies such as meningitis, facial paralysis, or peripheral neuritis. * Stage 3 (chronic persistent stage)-this is the late stage where symptoms may develop months to years after the tick bite. During this stage arthritis, chronic fatigue, and memory problems may develop. As with any infectious disease, if left untreated or poorly managed, Lyme disease can become a chronic and debilitating illness.
Complete recovery is likely when the disease is treated with appropriate antibiotics in the early stages. In later stages, response to treatment is slower, and mortality rates are increased. Incidence and Prevalence The incidence of Lyme disease in the United States is approximately “one in 2,719 out of 100,000 cases reported annually” (Bacon, Kugeler, & Mead, 2008). During the past ten years “93% of the cases have occurred in the Northeastern region of the United States, which includes Connecticut, Rhode Island, New York, New Jersey, Delaware, Pennsylvania, and Maryland, as well as Wisconsin” (Kruger, 2010).
In 1996, the Centers for Disease Control and Prevention “reported a record high number of 16,461 cases of Lyme disease in 45 states which is an increase of 41% from the 11,700 cases reported in 1995” (Bacon, Kugeler, & Mead, 2008). “Voluntary surveillance statistics from the CDC shows an estimated increase of 101% in the annual incidence of Lyme disease from 1992 to 2006 (Kruger, 2010). Population groups most at risk for Lyme disease are children five to sixteen years old and adults 35 to 50 years old; the lowest incidence in among those 20-24 years of age” (Kruger, 2010).
The increase in the number of reported cases is directly correlated to the increase in deer populations throughout the Northeastern region and the lack of education on ways to reduce the risk of tick-borne diseases. Pathophysiology Lyme disease is a multisystem infection caused by the spirochete Borrelia burgdorferi (B. burgdorferi); this spirochete is found to exist in “reservoir hosts”, such as deer’s, mice, squirrels, cats and dogs (Kruger, 2010). Spirochetes are motile, gram-negative, corkscrew shaped organisms that tend to have an affinity for collagen and connective tissues.
The interplay between the invading spirochetes and the subsequent host immune response plays an important part in the disease process. B. burgdorferi can spread throughout the body during the course of the disease and has been found in the skin, heart, joint, peripheral nervous system, and central nervous system. B. burgdorferi is injected into the skin by the bite of an infected Ixodes tick (black-legged deer tick) and transmission of the disease occurs after 12 to 24 hours of feeding on the skin (Hermann, Girschick, & Tappe 2009).
After initial injection of B.burgdorferi into the skin it begins to migrate outward and subsequently spread into the lymph, blood, and tissues. The incubation period from the time of exposure to onset of symptoms ranges from three to thirty days (Hermann, Girschick, & Tappe 2009). The tick’s saliva accompanies the spirochete into the skin during the feeding process the saliva contains proteins that disrupt the immune response at the site of the bite. The spirochetes multiply and migrate outward within the dermis causing “erythema migrans” (circular rash) (Robets & Glatz, 2008).
The host’s inflammatory response to the bacteria in the skin causes the characteristic circular lesion. Neutrophils, which are necessary to eliminate the spirochetes from the skin, fail to appear in the developing lesions thus allowing the bacteria to survive and spread throughout the body. It is believed the spirochetes avoid the immune response by decreasing expression of surface proteins that are targeted by antibodies antigenic (Auwaerter, 2007). This decreased expression inactivates the complement immune response which may interfere with the function of immune factors.
In the brain, B. burgdorferi may induce astrocytes to undergo astrogliosis (proliferation followed by apoptosis) which may contribute to neurodysfunction and cognitive impairment (Auwaerter, 2007). The spirochetes may also induce host cells to secrete products toxic to nerve cells, including quinolinic acid and the cytokines IL-6 and TNF-alpha, which can produce fatigue and malaise (Auwaerter, 2007). If untreated, the bacteria may persist in the body for months or even years, despite the production of anti-B. burgdorferi antibodies by the immune system.
There is no natural immunity to Lyme disease, once exposed re-infection with further exposure is possible. Also, there are no current vaccines available to treat Lyme disease. Researchers however are focusing efforts on identifying the component(s) of B. burgdorferi responsible for antibody-mediated bactericidal protection (Hermann, Girschick, & Tappe 2009). Through these efforts protection may be available to fight the arthritic manifestation of the disease. Case Study Subjective Data Chief Complaint: “I have been sick for a week and I got this rash on my leg that won’t go away”.
History of Present Illness: M.J. , a 32- year- old Hispanic female of Puerto Rican descent, Laurel, MD resident who presents to the urgent care facility with complaint of migratory joint pain especially in the knees, fatigue, chills, low grade fever for one week. The client denies recent travel out of the country but visited family members in North Carolina three weeks ago. Client reports a tick bite while hiking in North Carolina with her sister in a heavily wooded area near family home. She discovered the tick on her left calf twenty-four hours after hiking and removed the insect with tweezers.
Reports taking Motrin 200mg , one tablet by mouth every eight hours as needed for muscle pain, last dose was yesterday prior to bed, Neosporin on rash to left calf at bedtime and gargling with warm salt water four time daily to relieve jaw pain. Client reports no relief from interventions. Past Medical History: Reports history of chicken pox at the age of eight. Denies any acute or chronic adult illnesses; Denies hospitalizations, surgeries, or blood transfusions. Immunizations are up to date. Denies taking medications regularly; Denies food, environmental and drug allergies; Denies history of mental illness.
Family History: Paternal grandfather died 83 years old of CVA, Mother 68 years diagnosed with DM Type II at age 52. Father 72 years old diagnosed with HTN at age 48, one sister 28 years old alive and well. Social History: Single, no children, Catholic, living in a single family home. Reports working full- time as an IT consultant. Denies having pets; Denies use of alcohol, illicit drugs; Denies exposure to environmental hazards. Reports eating three times daily, well balanced nutritious meals and exercises three times a week. Review of Systems: Reports generalized fatigue, muscle and joint pain, a red rash on left leg.
Denies history of arthritis, denies numbness or tingling in upper or lower extremities, dizziness, loss of balance, blurred vision, nausea or vomiting. Reports difficulty chewing secondary to jaw pain; Reports throat tenderness when swallowing. Objective Data Vital Signs: Temperature 99. 6, pulse106, respirations 22, and blood pressure 148/86. Oriented x 3, obeys verbal commands, well groomed, cooperative, with good eye contact; exhibits facial grimacing when ambulating. Skin: Warm and dry with a macular, closed 15 cm circular erythematous rash with alternating concentric rings on the left side, upper trunk.
No drainage noted from site, skin grossly intact, warm to touch. Mouth/Throat: Buccal mucosa pink and moist; teeth in good repair, no lesions; throat erythematous; palpable, tender, and enlarged anterior cervical and tonsillar lymph nodes; tonsils enlarged (2+ grade); gag reflex intact, swallowing slowly. Musculoskeletal: Generalized muscle weakness in upper and lower extremities (MS +3); Pain 4+ when bending elbows and knees bilaterally, weak hand grip bilaterally (MS +3). Neurological: Coordinated, smooth steady gait. CN 1-12 intact; Reflexes 4; mental status appropriate for age.
Medical diagnosis – R/O Lyme disease; Differential diagnosis- Influenza, Cellulitis, Arthritis. Nursing diagnosis- Acute pain related to muscle ache; Alteration in skin integrity related to “bull’s eye” patterned skin rash; Risk for activity intolerance related to fatigue; Risk for immobility; Self care deficit related to muscle weakness. Treatment Plan Complete blood count with differential, chemistry profile, liver functions test, enzyme-linked immunoassay (ELISA) and Western blot (WB), erythrocyte sedimentation rate, IGM and IgG Pharmaceuticals: Doxycycline 100mg; one tablet by mouth every 12 hours for 28 days (Kinkel & Miravalle, 2009).
Ibuprofen 600mg ; one tablet by mouth every six hours not to exceed 3600 mg daily as needed for pain and stiffness (Gutierrez, 2008). Patient Education and Home Care When walking in heavily wooded areas or working in the yard and garden wear closed shoes, light colored clothes, shirts with longed sleeves, tucked in long-legged pants as well as pants tucked in socks and a hat to prevent ticks from getting onto the skin, hair and scalp. Use insect repellant that contains diethyltoluamide (DEET) on the skin and clothes to decrease the incident of tick bites Inspect the body for ticks especially the scalp, arms, and legs.
If any ticks are found, remove promptly by gently using tweezers or fingers (use a tissue) to grasp the tick by the base of its head. To avoid depositing content into the skin, do not squeeze the tick. Flush the tick down the commode; do not burn the tick in order to avoid spreading infection. Clean affected area with an antiseptic such as rubbing alcohol also, see the physician immediately if symptoms worsen (Buttaro, Trybulski, Baily, & Sandberg-Cook, 2008). Follow- up with healthcare provider after completion of medicinal therapy. Theoretical Framework.
Martha Rogers Science of Unitary Human Beings Nursing Theoretical Framework Rogers understood that a person is more than just the sum of their parts. She theorized that the identity of nursing as a science arises from the integrality of people and the environment that coordinates with a multidimensional universe of open systems (Meleis, 2007). The purpose of nursing is to promote health and wellbeing for all persons. The concept of the unitary human being guides nursing care by helping the nurse practitioner understand that care is not disease focused only, but focuses on the person holistically.
Therefore, when creating M. J. ’s plan of care, the practitioner will take into consideration her culture, profession, and lifestyle. Roger theory is applicable to this case study because it allows the nurse practitioner to enters into the environment of the client, and utilize the nursing process to make an assessment and ultimately deliver care. This theory provides the framework to establish a relationship between two unrelated beings brought together with an ultimate goal of wellness. Conclusion.
When treating Lyme disease it is especially important to integrate the components of the nursing process in order to recognize associated characteristics of the disease to avoid misdiagnoses. When caring for a patient it is imperative that the practitioner integrate the fundamental beliefs of a nursing theory in order to establish the foundation of care and effectively develop a plan of care, and maintain a professional, trusting relationship.
Reference Auwaerter, P. G. (2007) Point: antibiotic therapy is not the answer for patients with persisting symptoms attributable to Lyme disease.
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