Documentation Guidelines

• Physical changes: Vital signs, particularly blood pressure and temperature; daily weight, intake and output; signs of bleeding or tarry stools, petechiae, bruising, pallor

• Physical changes: Location site and description of any skin lesions or rashes and overall condition of the skin

• Physical changes: Presence of any seizure activity, visual disturbances, headaches, personality changes, or memory deficits

• Tolerance to activity, level of fatigue, patient's ability to perform activities of daily living and range of motion of extremities; note the extent of joint involvement and the presence of tingling, numbness, or weakness

Teach the patient the purpose, dosage, and possible side effects of all medications. Explain to the patient the disease process, the purpose of treatment regimens, and the importance of compliance. Teach the patient when to seek medical attention. Teach the patient to wear a Medic Alert bracelet noting the disease and medications so appropriate action can be taken in an emergency.

Teach the female patient the importance of planning pregnancies with medical supervision because pregnancy is likely to cause an exacerbation of the disease.

Discuss all precipitating factors that need to be avoided, including fatigue, vaccination, infections, stress, surgery, certain drugs, and exposure to ultraviolet light. Teach the patient how to minimize ultraviolet exposure. Teach the patient to avoid strenuous exercise, instead striving for a balance. Stress the importance of adequate nutrition. Small, frequent meals may be better tolerated. Any cosmetics should be approved by the physician and should be hypoallergenic. Encourage the patient to contact the Arthritis Foundation, the Lupus Foundation, and other appropriate support groups that are available in the area.

Lyme disease is a tick-borne illness that is an acute recurrent inflammatory disease characterized by periods of exacerbation and remissions. This disease is named for the town in Connecticut where it was first recognized in the 1970s. In the last 10 years, the number of cases has ranged from approximately 10,000 to 15,000 in the United States, making it the leading tickborne disease in the United States.

Lyme disease typically begins in summer or early fall and develops in three stages with varying, progressive symptoms over weeks and months if untreated. The most frequent carrier of the disease is the deer tick, a small insect the size of a poppy seed. The deer tick is predominantly found in the New England and mid-Atlantic states, Wisconsin, Minnesota, and northern California, although cases of Lyme disease have been documented in 48 states. Severe long-term effects occur in fewer than 10% of untreated cases. Complications include pericarditis and myocarditis, cardiac dysrhythmias, encephalitis, peripheral neuropathies, and arthritis. Incubation lasts 7 to 10 days, but diagnosis generally must wait for 4 to 6 weeks after the patient is bitten by a tick in order to make laboratory tests reliable.

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