CHAPTER THREE

PATIENT’S MANAGEMENT

3.0 MEDICAL MANAGEMENT

With appropriate antibiotic treatment, most patients with early-stage Lyme disease recover
rapidly and completely. Antibiotic selection, route of administration, and duration of therapy for
Lyme disease are guided by the patient’s clinical manifestations and stage of disease, as well as
the presence of any concomitant medical conditions or allergies.

Treatment of Lyme disease is as follows:

 Adult patients with early localized or early disseminated Lyme disease associated with
erythema migrans: Doxycycline, amoxicillin, or cefuroxime axetil

 Children under 8 years and pregnant or nursing women with early localized or early
disseminated Lyme disease: Amoxicillin or cefuroxime axetil

 Neurologic Lyme disease: IV penicillin, ceftriaxone, or cefotaxime; oral doxycycline,

when not contraindicated, in patients with Lyme-associated meningitis, facial nerve
palsy, or radiculitis

 Treatment of Lyme arthritis includes; Oral antibiotics for 28 days, re-treatment with oral
antibiotics for mild residual joint swelling, NSAIDs in patients with negative PCR,
supplemented if necessary with hydroxychloroquine. Consideration of arthroscopic
synovectomy in patients unresponsive to symptomatic therapy.

 Lyme carditis may be treated with either oral or parenteral antibiotic therapy for 14 days
(range, 14-21 days). Hospitalization and continuous monitoring, with consideration for
temporary pacing, are advisable for patients with cardiac dysfunctions.
3.1 SPECIFIC MEDICAL MANAGEMENT

On the day of admission that is 12th January, 2022, the following was instituted; physical
assessment and examination of the patient, interview was conducted on his friend who brought
him to the hospital and then his sister who was next of kin to obtain the patient’s bio-data, past
medical history, allergies and any other type of underlying medical condition. This was done in
order to get baseline data.

The following investigations were ordered:

 Full blood count: The PCV was normal, WBC count was high with 14,000 which is an
indication of infection.
 ELISA: The ELISA was done to detect the antibodies of the pathogens, however the
result was not definitive as it shows false-positive.
 Western blot test: This was done to confirm the results of the ELISA, and the result was
positive showing the antibodies of Borrelia burgdorferi.

The patient was administered the following medications in the emergency unit;
 IV prednisolone 10mg stat
 IM diclofenac 150mg stat

After the diagnosis of Lyme disease was confirmed; the patient was transfer to the male medical
ward and placed on the following medications;

 IV doxycycline 200mg stat, 100mg 6 hourly

 IV amoxicillin 500mg 8 hourly

 IM diclofenac 75mg 8 hourly

 IV fluids, Normal Saline alternate with 5% Dextrose Saline 6 hourly

3.2 DIAGNOSTIC INVESTIGATIONS

The diagnosis of Lyme disease is typically based on history and physical examination. However,
the diagnosis were confirmed with blood tests, which look for antibodies against Borrelia. This
started with enzyme-linked immune-sorbent assay (ELISA) and was then confirmed with
Western blot. The diagnosis is confirmed only when both tests come back positive. However, it’s
important to keep in mind that these tests can initially give false-negative results, as the
development of antibodies to a detectable level, called sero-conversion, may take up to 8 weeks.
In addition to full blood count tests, the blood test also showed elevated inflammatory markers
like erythrocyte sedimentation rate, or ESR for short.

DIAGNOSTIC INVESTIGATIONS

S/N Name of Patient’s test result Normal value Interpretation

test

1. Full blood pcv: 45% pcv: 39% - 49% The PCV was
count normal, WBC
wbc: 14,000 wbc: 4,000 –
count was high
cells/mcL 10,000
with 14,000
cells/mcL
platelet count: which is an
270,000 cells/mcL plateletcount: indication of
135,000 – infection.
esr: 25 mm/hr
350,000 The elevated-
cells/mcL erythrocyte

esr: 1 – 20 sedimentation
mm/hr rate is also an
indication for
infection and
 inflammation.

2. ELISA False-positive False-negative The ELISA was

done to detect the
False-positive
antibodies of the
Positive pathogens,
however the
result was not
definitive as it
shows false-
positive.

3. Western Positive Negative This was done to

blot test confirm the
Positive
results of the
ELISA, and the
result was
positive showing
the antibodies of
Borrelia
burgdorferi.

3.3 DRUG LITERATURE

The antibiotic regimen for Lyme disease depends on the stage and manifestations of the disease,
as well as on patient factors. Antimicrobial therapy typically focuses on Borrelia burgdorferi
sensu lato, but should cover all likely pathogens in the context of the clinical setting. Coverage
for co-infecting organisms, such as Ehrlichia species, should be considered, especially in patients
with atypical clinical presentations.
Name Group Routes of Indicatio Contrain Mode of Side Nursing
Administ ns dications Action Effects Consider
ration ations

Doxycycl Antibiotic Oral skin and Hypersen It inhibit Anemia, Encourag

ine s soft tissue sitive protein Headache e patient
(tetracycli infections reactions, synthesis , to take
ne) , by epigastric liberal
Third
pharyngit binding to pain, fluid with
trimester
is, 30S dizziness, drug to
of
tonsillitis, ribosome nausea, wash the
pregnanc
sinusitis s in the vomiting capsule to
y.
otitis bacteria. reduce
media risk of
GIT
irritation.

Drug
should be
taken 1hr
before or
2hrs after
meal.

Amoxicil Antibiotic oral ENT Hypersen It inhibit Anemia, Avoid

lin s infections sitive cell wall Headache concurren
, urinary reactions synthesis , t use of
tract epigastric erythrom
infections pain, ycin.
, skin and dizziness,
Ensure
 soft tissue vomiting patient is
infections not
allergic to
amoxicilli
n.

Prednisol Corticost Oral, Arthritis, Hypersen It inhibits Weight Drug

one eroid intraveno inflamma sitive inflamma gain, should be
drug usly, tory reaction, tory shortness taken
topically condition wound/ processes of breath, with food
s, auto- bone or urticarial, to prevent
immune healing, responses pruritus, stomach
disease, diabetes, in the nausea upset.
skin brain body. and
Encourag
condition, injury, vomiting,
e patient
eye osteoporo headache.
to take
condition, sis..
liberal
severe
fluid with
allergic
drug to
reaction,
wash the
breathing
capsule to
problem.
reduce
risk of
GIT
irritation.

Diclofena NSAID, Oral, Pains, Peptic It inhibits Headache It should

c Analgesic intraveno Sprains, ulcer, prostagla , not be
us, General ulcerative ndin epigastric given to
 intramusc body pain colitis, biosynthe pain, peptic
ular asthma sis dizziness, ulcer
thereby vomiting, patients.
preventin
It should
g pain
be
administe
red with
caution to
pregnant
women
and
lactating
mothers.

3.4 NURSING MANAGEMENT OF THE PATIENT (NURSING PROCESS: ADPIE)

ASSESSMENT: Assessment and history taking was done on the patient, he talked about his
recent farming activities when he found a tick on his thigh. He pulled it off and didn’t think
about it until later when he saw a large rash on his thigh that looked like a bulls-eye. He said the
rash has gotten bigger over the past three days and that it is painless. The rash is raised along the
edges and flat in the middle.

His vital signs are temperature 39.6 C, heart rate is 92 beats per minute, respiratory rate is 20
breaths per minute, blood pressure 128/86 mmHg, SpO2 99% on room air, and pain 7/10 located
mostly in his joints.
Subjective Data: Initial Symptoms Headache, Fatigue, Muscle / joint pain, Neck stiffness, Nerve
pain, Short-term memory loss, Dizziness, Shortness of breath.

Objective Data: Bullseye rash (erythema migrans), Fever / chills, Swollen lymph nodes, Facial
palsy, Inflammation of the brain / spinal cord, Palpitations and irregular heartbeats.

DIAGNOSIS: After performing assessment on the patient, the following nursing diagnoses were
formulated which include; acute pain related to erosion of the mucosa layer evidence by patient’s
verbalization of intense pain at the joints, imbalance nutrition less than body requirement related
to anorexia evidence by weight loss and emaciation, anxiety related to disease condition
evidence by patient’s worrisome facial expression, and others included elevated body
temperature related to infectious process; fatigue related to illness; pain related to joint
inflammation; and readiness for enhanced health management related to new therapeutic
treatment regimen.

OUTCOME IDENTIFICATION: Patient will be infection free, manage and reduce pain and
inflammation; regain optimal mobility, prevent complications

PLANNING: After the nursing diagnosis, the goals of care for Mr F.A were planned. He will
report joint pain and stiffness, he will show signs of balanced nutrition status, less fatigue, less
anxiety and his temperature will be within normal limits and he will also adhere to his treatment
regimen and incorporate ways to prevent Lyme disease when spending time outdoors.

IMPLEMENTATION: The plans for Mr F.A were implemented by the nursing team which
included the senior nursing officers, nursing officers and student nurse. The physician prescribes
the antibiotic doxycycline. The patient was instructed to take each dose with a full glass of water
and to finish the entire course, even if he feels better after a few days. For his joint stiffness,
pain, and fever, the physician recommends an NSAID like ibuprofen. The nursing officer and I
emphasize on the importance of letting his physician know if he experiences problems such as
neck stiffness, increased joint pain, lightheadedness, or palpitations. Finally, the entire nursing
team in charge of the care of Mr F.A review how to prevent tick bites when he goes to the farm
by making sure his skin is sufficiently covered, and by using insect repellent with DEET as well
as checking his whole body for ticks in any area where ticks are likely to be found.
EVALUATION: After the implementation of nursing interventions, the patient was evaluated.
He states that he completed the entire course of doxycycline and that he feels much better. His
temporal temperature is 98.9 F or 37.1 C and he rates his pain at 2/10 located in his joints. He
said that he is a lot more conscientious of ticks when outdoors and during camping trips.

COMPLICATIONS OF LYME DISEASE

Arthritis: Prolonged infection with Lyme disease leads to chronic joint inflammation and
swelling, usually in the knees (though other joints can be affected). These symptoms tend to arise
within two years of infection, with periods of flare-ups and remissions. This arthritis is relatively
difficult to manage, though antibiotics and steroids may be attempted.

Lyme carditis: If the bacteria reach the heart tissues, they can cause inflammation and lead to
“heart block.” The electrical signals being sent between the upper and lower chambers of the
heart are interrupted, impairing the coordination of the heartbeat. Though disruptive, this is
rarely fatal.

Lyme neuroborreliosis: Inflammation of multiple nerves, including those in the spine and brain,
is the chief characteristic of this condition. This can also affect the meninges the layer of tissue
surrounding the brain and spine leading to meningitis, among other conditions. Antibiotic
therapy, if applied promptly, tends to be effective as a treatment.

Fibromyalgia Syndrome: Similar studies have found temporal links between Borrelia infection
and the development of clinically diagnosable Fibromyalgia, the etiology of which is generally
multifactorial and can be triggered by environmental factors, trauma, stress, infection, and
possibly vaccination.

Neurological Disorders: Neurological and mental health co-morbidities develop in

approximately 5% of Lyme disease patients, especially if the disease is not successfully treated
initially. Neurological sequelae include radiculopathy and paresthesias in the extremities.
Associated mental health changes include mild cognitive impairments, mood disorders,
depression, and anxiety.
PROGNOSIS OF PATIENT

The prognosis for patients with Lyme disease is generally excellent when they are treated early
with appropriate antibiotic regimens. However, recurrent infection is possible if the patient is
again bitten by an infected tick; these infections are usually due to a different strain of the local
Borrelia (Nau, Christen & Eiffert 2019).

Patients, especially adults, who receive late treatment or initial treatment with antibiotics other
than doxycycline or amoxicillin may develop chronic musculoskeletal symptoms and difficulties
with memory, concentration, and fatigue. These symptoms can be debilitating and hard to
eradicate.

Some patients develop chronic arthritis that is driven by immune-pathogenic mechanisms and
not active infection. This condition is more prevalent among individuals with HLA-DR2, HLA-
DR3, or HLA-DR4 allotypes. The arthritis is resistant to antibiotic treatment but typically
responds to symptomatic treatment and shows eventual resolution (Steere & Angelis 2016).

Cardiac involvement in Lyme disease is rarely chronic. However, patients with third-degree
heart block often require a temporary pacemaker insertion and, on rare occasions, a permanent
pacemaker insertion.

Lyme disease appears to rarely be fatal. Many of the fatal cases reported have been in patients
co-infected with other tick-borne pathogens such as Ehrlichia species and B microti, and in
Europe, tick-borne encephalitis. A US Centers of Disease Control and Prevention (CDC) study
of death records from 2009-2013 found that only one of 114 total records listing Lyme disease as
an underlying or multiple cause of death was consistent with clinical manifestations of Lyme
disease (Kugeler, Griffith & Gould 2021).

For Mr F.A, the prognosis was good, very satisfactory and this was attributed to early diagnosis
and with appropriate treatment regimens. The patient’s signs and symptoms declined in the
second week of admission with any form of complications and by third week the patient was in
full remission.
3.5 NURSING CARE PLAN:

S/ Nursing Nursing Nursing Scientific Evaluation

N Diagnosis Objectives Interventions Rationale

1. Acute pain Patient will Assess the To determine Patient was

related to erosion verbalize relief patient’s level of the level of relieved of pain
of the mucosa of pain within pain using pain within three of
layer evidence two to three numerical rating experienced by nursing
by patient’s hours of of 1 to 10. the patient. intervention.
verbalization of nursing
intense pain at intervention. Place patient in Placing the
the joints. a comfortable patient in
position. comfortable
position will
Apply cool help relieve
compress on pain.
swollen knees
and joints Cool compress
provides pain
Administer relief and
prescribed pain reduces the
medication swelling.
(analgesic) e.g
paracetamol Analgesic
600mg relieves pain by
blocking the
 pain receptors.

2. Imbalance Patient’s Check patient To establish Patient’s

nutrition less nutritional state weight daily. baseline data. nutritional state
than body will be will be balanced
requirement balanced within Monitor To assess the within 48 hours
related to 48 hours of patient’s input fluid and of nursing action.
anorexia nursing action. and output chart. electrolyte
evidence by balance.
Serve patient
weight loss and balance diet in Balance diet
emaciation. moderate provides
portion. nourishment
and energy
Administer which are
prescribed necessary for
medication patient’s to
(anti-emetics) recovery.
e.g
promethazine Anti-emetic
0.5mg. drugs inhibit
vomiting.

3. Anxiety related Patient will Establish a To foster trust Patient was calm,
to disease demonstrate therapeutic and cooperation demonstrated no
condition less anxiety relationship with from patient. signs of anxiety,
evidence by after 24 hours patient. and was able to
patient’s of nursing To make interact freely
worrisome facial intervention. Encourage patient feel with other
expression. patient to secured. patients in the
verbalize his or ward.
her feelings. To prevent
unnecessary
Decrease panic attack
sensory stimuli which might
by maintaining increase
quiet sensory stimuli
environment. and anxiety.

Give patient To alley

reassurance. anxiety.
3.6 HEALTH EDUCATION

Clinicians should educate parents and children who live in endemic areas about the risk of Lyme
disease. Education and awareness are the best means of preventing Lyme disease. Anticipatory
guidance should focus on prevention measures and post–tick exposure counseling on watching
for symptoms and signs of Lyme disease. Personal strategies for preventing Lyme disease fall
into two categories: personal habit modification (eg, avoiding ticks/tick habitats, inspecting
clothing and pets, using repellents) and prophylaxis.

The patient was educated on the early stages of Lyme disease about symptoms that can develop
later. Development of these symptoms necessitates re-examination and may indicate treatment
failure or incorrect diagnosis. The patient was advised on the side effect of doxycycline, as this
antibiotic can cause severe cutaneous photosensitivity. The patient was cautioned to use
sunblock with a sun protection factor (SPF) of at least 30 and to wear wide-brimmed hats for
further protection.

The patients was also informed that antibodies induced by the infection are not protective against
further exposures to Borrelia burgdorferi; one episode of erythema migrans does not always
confer immunity to the next. Consequently, preventive strategies against lyme disease remain
important for patients.

3.7 DISCHARGE AND FOLLOW UP CARE

Following the patient’s good prognosis and the attending doctor’s satisfaction with the
prognosis, the patient was discharge on 30 th of January 2022, having being admitted for three (3)
weeks in the hospital. However, a follow up appointment was schedule 2 weeks after discharge.
The patient was given medications to be used at home for 2 weeks, after which he would visit the
hospital for the scheduled follow up appointment and to be seen by the attending physician.
3.8 ADVICE ON DISCHARGE

The patient was given the following advice upon discharge from the hospital;

1. Always use your medications as prescribed by the doctors.

2. Eat adequate diet to ensure balanced nutrition.

3. Ensure maximum rest and sleep.

4. Engage in moderate exercise thirty minutes (30mins) daily.

5. Follow up with next scheduled appointment at the hospital.

6. Report back to the hospital, in case of any new complaints.

7. Avoid tick-infested areas, especially during summer months.

8. Walk on cleared or paved surfaces when available, rather than tall grass.

9. Wear long pants, sleeved shirts, and close-toed shoes.

10. Light-colored clothing makes it easier to locate a tick.

11. Always check for ticks whenever coming from outdoors. The risk of Lyme disease is
minimized when the tick is removed within 36 hours.

12. Showering immediately after being outdoors reduces the risk of tick attachment

13. Wash clothing that's been outdoors (dryer kills ticks)

14. Remove the tick only by using tweezers to pull the tick directly off the skin (no twisting)

15. After removal of the tick, wash site with soap and water and then swab the area with
antiseptic.

3.9 SUMMARY OF CARE STUDY

This is a care study of Mr F.O, a 42 years old man admitted into the male medical ward of
Nnamdi Azikiwe University Teaching Hopsital, Awka, Anambra State on the 12 th of January,
2022 and was discharge on 30th of January 2022, having being admitted for three (3) weeks in the
hospital.

Upon discharge, the patient was given medications to be used at home for 2 weeks, after which
he would visit the hospital for the scheduled follow up appointment. Mr F.O was also advised on
the prevention of the re-occurrence of lyme disease.

Finally, this care study has increased my knowledge about lyme disease. As a student-nurse, the
experience gotten from caring for Mr. F.O for three weeks will be an added advantage in the
pursuit of my professional career in Nursing.

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