Lyme Disease

Case Study

A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent complaints of headache, fever, chills, myalgia, and arthralgia. According to the history, the patient’s symptoms began shortly after a camping vacation. He recalled a bug bite and rash on his thigh immediately after the trip. The following studies were ordered:

Studies

Results

Lyme disease test,

Elevated IgM antibody titers against Borrelia burgdorferi (normal: low)

Erythrocyte sedimentation rate (ESR),

30 mm/hour (normal: ≤15 mm/hour)

Aspartate aminotransferase (AST),

32 units/L (normal: 8-20 units/L)

Hemoglobin (Hgb),

12 g/dL (normal: 14-18 g/dL)

Hematocrit (Hct),

36% (normal: 42%-52%)

Rheumatoid factor (RF),

Negative (normal: negative)

Antinuclear antibodies (ANA),

Negative (normal: negative)

Diagnostic Analysis

Based on the patient’s history of camping in the woods and an insect bite and rash on the thigh, Lyme disease was suspected. Early in the course of this disease, testing for specific immunoglobulin (Ig) M antibodies against B. burgdorferi is the most helpful in diagnosing Lyme disease. An elevated ESR, increased AST levels, and mild anemia are frequently seen early in this disease. RF and ANA abnormalities are usually absent.

Critical Thinking Questions

1. What is the cardinal sign of Lyme disease? (always on the boards)

2. At what stages of Lyme disease are the IgG and IgM antibodies elevated?

3. Why was the ESR elevated?

4. What is the Therapeutic goal for Lyme Disease and what is the recommended treatment.

Peripheral Vascular Disease

Case Studies

A 52-year-old man complained of pain and cramping in his right calf caused by walking two blocks. The pain was relieved with cessation of activity. The pain had been increasing in frequency and intensity. Physical examination findings were essentially normal except for decreased hair on the right leg. The patient’s popliteal, dorsalis pedis, and posterior tibial pulses were markedly decreased compared with those of his left leg.

Studies

Results

Routine laboratory work

Within normal limits (WNL)

Doppler ultrasound systolic pressures

Femoral: 130 mm Hg; popliteal: 90 mm Hg; posterior tibial: 88 mm Hg; dorsalis pedis: 88 mm Hg (normal: same as brachial systolic blood pressure)

Arterial plethysmography

Decreased amplitude of distal femoral, popliteal, dorsalis pedis, and posterior tibial pulse waves

Femoral arteriography of right leg

Obstruction of the femoral artery at the midthigh level

Arterial duplex scan

Apparent arterial obstruction in the superficial femoral artery

Diagnostic Analysis

With the clinical picture of classic intermittent claudication, the noninvasive Doppler and plethysmographic arterial vascular study merely documented the presence and location of the arterial occlusion in the proximal femoral artery. Most vascular surgeons prefer arteriography to document the location of the vascular occlusion. The patient underwent a bypass from the proximal femoral artery to the popliteal artery. After surgery he was asymptomatic.

Critical Thinking Questions

1. What was the cause of this patient’s pain and cramping?

2. Why was there decreased hair on the patient’s right leg?

3. What would be the strategic physical assessments after surgery to determine the adequacy of the patient’s circulation?

4. What would be the treatment of intermittent Claudication for non-occlusion?

 

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 Lyme Disease 

A 38-year-old male had a 3-week history of fatigue and lethargy with intermittent complaints of headache, fever, chills, myalgia, and arthralgia. According to the history, the patient’s symptoms began shortly after a camping vacation. He recalled a bug bite and rash on his thigh immediately after the trip. The following studies were ordered: 

Studies Results Lyme disease test, Elevated IgM antibody titers against Borrelia burgdorferi (normal: low) 

Erythrocyte sedimentation rate (ESR), 30 mm/hour (normal: ≤15 mm/hour) Aspartate aminotransferase (AST), 32 units/L (normal: 8-20 units/L) 

Hemoglobin (Hgb), 12 g/dL (normal: 14-18 g/dL) 

Hematocrit (Hct), 36% (normal: 42%-52%) 

Rheumatoid factor (RF), Negative (normal: negative) 

Antinuclear antibodies (ANA), Negative (normal: negative) 

Diagnostic Analysis 

Based on the patient’s history of camping in the woods and an insect bite and rash on the thigh, Lyme disease was suspected. Early in the course of this disease, testing for specific immunoglobulin (Ig) M antibodies against B. burgdorferi is the most helpful in diagnosing Lyme disease. An elevated ESR, increased AST levels, and mild anemia are frequently seen early in this disease. RF and ANA abnormalities are usually absent. 

Critical Thinking Questions 

1. What is the cardinal sign of Lyme disease? (always on the boards) 

2. At what stages of Lyme disease are the IgG and IgM antibodies elevated? 

3. Why was the ESR elevated? 

4. What is the Therapeutic goal for Lyme Disease and what is the recommended treatment.

Peripheral Vascular Disease

 A 52-year-old man complained of pain and cramping in his right calf caused by walking two blocks. The pain was relieved with cessation of activity. The pain had been increasing in frequency and intensity. Physical examination findings were essentially normal except for decreased hair on the right leg. The patient’s popliteal, dorsalis pedis, and posterior tibial pulses were markedly decreased compared with those of his left leg. 

Studies Results Routine laboratory work Within normal limits (WNL) 

Doppler ultrasound systolic pressures Femoral: 130 mm Hg; popliteal: 90 mm Hg; posterior tibial: 88 mm Hg; dorsalis pedis: 88 mm Hg (normal: same as brachial systolic blood pressure) 

Arterial plethysmography Decreased amplitude of distal femoral, popliteal, dorsalis pedis, and posterior tibial pulse waves 

Femoral arteriography of right leg Obstruction of the femoral artery at the midthigh level 

Arterial duplex scan Apparent arterial obstruction in the superficial femoral artery 

Diagnostic Analysis 

With the clinical picture of classic intermittent claudication, the noninvasive Doppler and plethysmographic arterial vascular study merely documented the presence and location of the arterial occlusion in the proximal femoral artery. Most vascular surgeons prefer arteriography to document the location of the vascular occlusion. The patient underwent a bypass from the proximal femoral artery to the popliteal artery. After surgery he was asymptomatic. 

Critical Thinking Questions 

1. What was the cause of this patient’s pain and cramping? 

2. Why was there decreased hair on the patient’s right leg? 

3. What would be the strategic physical assessments after surgery to determine the adequacy of the patient’s circulation? 

4. What would be the treatment of intermittent Claudication for non-occlusion? 

 

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Case Study, Chapter 10, Principles and Practices of Rehabilitation

1. Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient’s right side is paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medical-surgical unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not reposition her for hours. 

1. Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?
2. What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

2. You are assigned to care for David Ramsey, a 22-year-old male patient who sustained a back injury secondary to being thrown from a motorcycle. He did not damage the spinal cord, but the computed tomography revealed a compression fracture at L-2 (lumbar area). David complains of severe lower back pain with numbness and tingling in the lower extremities. You identify the following nursing diagnosis: Impaired Physical Mobility.

1. What assessments are indicated based on this nursing diagnosis?
2. List other major nursing diagnoses based on David’s clinical presentation.

 

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Case Study, Chapter 12, Pain Management

1. Mr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and Oxycodone 10 mg every 4 hours PRN for severe pain. 

1. Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why?
2. What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring?
3. What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management?

2. Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82. 

1. What are benefits of epidural versus systemic administration of opioids?
2. The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. What is the rationale for these frequent assessments?
3. The nurse monitors Mr. Rogers for what other complications of epidural analgesia?
4. Mr. Rogers complains of a severe headache. What should the nurse do?
5. Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation?

 

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Case Study, Chapter 14, Shock and Multiple Organ Dysfunction Syndrome

1. Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. 

1. What predisposed the patient to develop septic shock?
2. What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?
3. The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?
4. Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?
5. Explain the importance for nutritional support for this patient and which type of nutritional support should be provided?

2. Carlos Adams was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are as follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented, but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock.

The following orders are written for the patient:

Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/line

Obtain complete blood count, serum electrolytes

Oxygen at 2 L/min via nasal cannula

Type and cross for 4 units of blood

Flat plate of the abdomen STAT

(Learning Objectives 1, 4, and5)

1. Describe the pathophysiologic sequence of events seen with hypovolemic shock.
2. What are the major goals of medical management in this patient?
3. What is the rationale for placing two large-bore IVs?
4. What are advantages of using 0.9% NS in this patient?
5. What is the rationale for placing the patient in a modified Trendelenburg position?

 

 

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