Lyme disease is a tick-borne illness caused by the bacterium Borrelia burgdorferi. This nursing diagnosis focuses on identifying and treating Lyme disease symptoms, preventing complications, and managing acute and chronic manifestations.
Causes (Related to)
Lyme disease affects patients in various ways, with several factors contributing to its progression and severity:
- Infection caused by Borrelia burgdorferi bacteria transmitted through tick bites
- Delayed diagnosis or treatment initiation
- Compromised immune system due to underlying conditions
- Risk factors such as:
- Outdoor activities in endemic areas
- Occupational exposure
- Living in or visiting wooded areas
- Having pets that go outdoors
- Environmental factors include:
- High-risk geographic locations
- Seasonal variation (peak in summer months)
- Outdoor recreational activities
- Inadequate protective clothing
Signs and Symptoms (As evidenced by)
Lyme disease presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Bull’s-eye rash (erythema migrans)
- Fatigue and malaise
- Joint pain and swelling
- Muscle aches
- Headache
- Fever and chills
- Neck stiffness
- Memory problems
- Sleep disturbances
Objective: (Nurse assesses)
- Characteristic erythema migrans rash
- Elevated temperature
- Swollen lymph nodes
- Joint inflammation
- Cardiac abnormalities
- Neurological symptoms
- Bell’s palsy
- Cognitive changes
- Signs of arthritis
Expected Outcomes
The following outcomes indicate successful management of Lyme disease:
- The patient will complete the prescribed antibiotic therapy
- The patient will demonstrate an understanding of tick-prevention measures
- The patient will report decreased joint pain and fatigue
- The patient will maintain a normal temperature
- The patient will show improved mobility
- The patient will demonstrate proper self-care techniques
- The patient will avoid complications
- The patient will return to normal daily activities
Nursing Assessment
Monitor Vital Signs
- Check temperature, pulse, respiratory rate, and blood pressure
- Document any cardiac irregularities
- Monitor for signs of infection
Assess Skin
- Inspect for erythema migrans rash
- Document size and appearance of rash
- Check for additional tick bites
- Monitor skin integrity
Evaluate Musculoskeletal Status
- Assess joint mobility and swelling
- Document pain levels
- Monitor physical activity tolerance
- Note any limitations in movement
Check Neurological Status
- Assess cognitive function
- Monitor for facial paralysis
- Document any sensory changes
- Evaluate muscle strength
Review Risk Factors
- Document exposure history
- Assess outdoor activities
- Review preventive measures
- Monitor for recurring symptoms
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Pain related to the inflammatory response to Borrelia burgdorferi infection as evidenced by reported joint pain, muscle aches, and decreased mobility.
Related Factors:
- Inflammatory response to infection
- Joint inflammation
- Muscle involvement
- Neurological complications
Nursing Interventions and Rationales:
- Assess pain characteristics and intensity
Rationale: Establishes baseline and monitors treatment effectiveness - Administer prescribed medications
Rationale: Manages pain and reduces inflammation - Teach pain management techniques
Rationale: Empowers patient with self-management strategies - Promote proper body mechanics
Rationale: Reduces joint stress and prevents additional pain
Desired Outcomes:
- The patient will report decreased pain levels
- The patient will demonstrate effective pain management techniques
- The patient will maintain optimal mobility
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Secondary Infection related to compromised immune system and current bacterial infection as evidenced by active Lyme disease.
Related Factors:
- Presence of B. burgdorferi infection
- Compromised immune response
- Antibiotic therapy
- Skin integrity changes
Nursing Interventions and Rationales:
- Monitor for signs of secondary infection
Rationale: Enables early intervention - Ensure proper antibiotic administration
Rationale: Maintains therapeutic levels of medication - Teach infection prevention strategies
Rationale: Reduces risk of complications
Desired Outcomes:
- The patient will complete antibiotic therapy as prescribed
- The patient will demonstrate an understanding of infection prevention
- The patient will remain free from secondary infections
Nursing Care Plan 3: Fatigue
Nursing Diagnosis Statement:
Fatigue related to the inflammatory process and systemic infection as evidenced by decreased energy levels and activity intolerance.
Related Factors:
- Systemic infection
- Sleep disturbances
- Inflammatory response
- Chronic pain
Nursing Interventions and Rationales:
- Assess energy levels and activity tolerance
Rationale: Establishes baseline for intervention planning - Implement energy conservation techniques
Rationale: Maximizes available energy - Promote adequate rest periods
Rationale: Supports healing and recovery
Desired Outcomes:
- The patient will report improved energy levels
- The patient will demonstrate effective energy conservation
- The patient will maintain a balance between activity and rest
Nursing Care Plan 4: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to joint inflammation and muscle weakness as evidenced by difficulty with movement and decreased range of motion.
Related Factors:
- Joint inflammation
- Muscle weakness
- Pain
- Fatigue
Nursing Interventions and Rationales:
- Assess mobility limitations
Rationale: Identifies specific needs for intervention - Implement an appropriate exercise program
Rationale: Maintains joint function and muscle strength - Teach proper body mechanics
Rationale: Prevents injury and promotes safe movement
Desired Outcomes:
- The patient will demonstrate improved mobility
- The patient will maintain joint function
- The patient will perform ADLs independently
Nursing Care Plan 5: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to unfamiliarity with Lyme disease management and prevention as evidenced by questions about care and prevention methods.
Related Factors:
- Limited exposure to information
- Complexity of disease process
- Misconceptions about treatment
- Need for lifestyle modifications
Nursing Interventions and Rationales:
- Provide disease education
Rationale: Increases understanding of the condition - Teach prevention strategies
Rationale: Reduces risk of reinfection - Demonstrate tick removal techniques
Rationale: Ensures proper handling of future exposures
Desired Outcomes:
- The patient will verbalize understanding of Lyme disease
- The patient will demonstrate proper prevention techniques
- The patient will identify early symptoms of infection
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Bratton RL, Whiteside JW, Hovan MJ, Engle RL, Edwards FD. Diagnosis and treatment of Lyme disease. Mayo Clin Proc. 2008 May;83(5):566-71. doi: 10.4065/83.5.566. PMID: 18452688.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Hatchette TF, Davis I, Johnston BL. Lyme disease: clinical diagnosis and treatment. Can Commun Dis Rep. 2014 May 29;40(11):194-208. doi: 10.14745/ccdr.v40i11a01. PMID: 29769842; PMCID: PMC5864449.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Wright WF, Riedel DJ, Talwani R, Gilliam BL. Diagnosis and management of Lyme disease. Am Fam Physician. 2012 Jun 1;85(11):1086-93. PMID: 22962880.
