2. Lyme disease: a spirochetal illness (syndrome); most common tick-borne infectious disease in United States; prevalent Northeast, upper Midwest, and coastal northern California. Reporting is mandatory. With early treatment, recovery is usually quick and complete.
   1. Stages:
      1. Stage I. Rash (erythema migrans) at site ot tick bite; bull’s-eye or target pattern; may appear as hives or cellulitis; common in moist areas (groin, armpit, behind knees). Flulike symptoms may occur (joint pain, chills, fever).
      2. Stage II. If untreated, may progress to cardiac problems (10% of patients) or neurological disturbances - Bell’s palsy (10% of patients); occasionally meningitis, encephalitis, and eye damage may result.
      3. Stage III. From 4 wk to 1 yr after the tick bite, “arthritis,” primarily large joint, develops in half the patients. If untreated, chronic neurological problems may develop.
   2. Assessment (depends on stage): History is important - where do they live or work? Recent travel? Outdoor activities (gardening, hiking, camping, clearing brush)? Knowledge of tick bite and how removed? Pets?
      1. Subjective data:
         1. Malaise (stage I).
         2. Headache (stage I).
         3. Joint, neck, or back pain (stages I and III).
         4. Weakness (stages II and III).
         5. Chest pain (stage II).
         6. Light-headedness (stage II).
         7. Numbness, pain in arms or legs (stage III).
      2. Objective data:
         1. Rash - erythema migrans (stage I); at least 5 cm/lesion.
         2. Dysrhythmias; heart block (stage II).
         3. Facial paralysis (stage II).
         4. Conjunctivitis, iritis, optic neuritis (stage
         5. Lab data: Lyme titer - elevated (stages II and III). Often inconclusive.
         6. Diagnostic tests: isolation of Borrelia burgdorferi in tissue or body fluid; diagnostic levels of IgM or IgG antibodies in serum or CSF.
   3. Analysis/nursing diagnosis:
      1. Anxiety related to diagnosis.
      2. Pain related to joint inflammation.
      3. Fatigue related to viral illness.
      4. Impaired physical mobility related to joint pain.
      5. Altered thought processes related to neurological deficit.
      6. Decreased cardiac output related to dysrhythmias.
      7. Knowledge deficit (learning need) related to treatment and course of disease.
   4. Nursing care plan/implementation:
      1. Goal: minimize irreversible tissue damage and complications.
         1. Medications according to presenting symptoms: stage I - oral antibiotics for 21 days (doxycycline, amoxicillin, cefotaxime); stages II and III - oral (see stage I) or intravenous antibiotics for 21-28 days (ceftriaxone).
         2. If hospitalized, monitor vital signs q4h for increased temperature, signs of heart failure; check level of consciousness and cranial nerve functioning.
         3. Note treatment response: worsening of symptoms during first 24 hr; redder rash, higher fever, greater pain (Jarisch-Herxheimer reaction).
      2. Goal: alleviate pain, promote comfort.
         1. Medications: salicylates, nonsteroidal anti-inflammatory agents, or other analgesic, as ordered; observe for side effects (GI irritation).
         2. Rest: give instructions on relaxation techniques; create a quiet environment.
         3. Goal: maintain physical and psychological well-being.
            1. Activity: ROM at regular intervals; medicate for pain before exercise; encourage proper posture to reduce joint stress; rest periods between activities and treatments.
            2. Referral: occupational or physical therapy as appropriate.
            3. Reassurance: give psychological support; encourage discussion of feelings.
         4. Goal: health teaching.
            1. Information on disease. Transmission from tick not likely if removed before 48 hours of attachment.
            2. Instructions for home IV antibiotics with heparin lock, if ordered.
            3. Side effects of antibiotics (drug specific); importance of completing therapy.
            4. Signs of disease recurrence (later stages of disease: less severe attacks).
            5. Preventing subsequent infections: wear proper clothing and tick repellent on clothing (20-30% DEET); conduct “tick checks” of self, children, and pets; proper tick removal (use tweezers, steady, gentle traction).
            6. Start vaccination series (LYMErix); three injections at 0, 1, and 12 months.
   5. Evaluation/outcome criteria:
      1. Achieves reasonable comfort.
      2. Regains normal physiological and psychological functioning - no irreversible complications; vital signs within normal limits.
      3. Resumes previous activity level; returns to work
      4. Adheres to follow-up care recommendations.
      5. Knows ways to minimize risk of reinfection.