MENIERE'S DISEASE

1.)What are the signs and symptoms according to subjective and objective assesment

vertigo Fluctuating, progressive, unilateral (in one ear) or bilateral (in both ears) hearing loss. A sensation of fullness or pressure in one or both ears. Unilateral or bilatera ltinnitus abnormal side-to-side eye movements, known as nystagmus ataxia , or an abnormal, unsteady walking gait

2.) Give atleast 3 Nursing Diagnosis of this specific client then prioritize

Anxiety r/t the sudden episodes of complete disorientation that cause the person to fall secondary to vertigo

Altered comfort r/t the sensation of spinning motion, fluctuating hearing loss, and tinnitus Risk for injury r/t the disorder of the inner ear

PRIORITIZATION

NURSING PROBLEM RANK JUSTIFICATIONAnxiety r/t the sudden episodes of complete disorientation that cause the person tofall secondary to vertigo

1 The nature of the problem high. It is considered as an actual factor. It belongs to the basic physiologic need in Maslow’s Hierarchy of Needs. In terms of the resources, both the client and the nurse have sufficient resources.

Altered comfort r/t the sensation of spinning motion, fluctuating hearing loss, andtinnitus

2 The nature of the problem is medium. It is considered as an actual factor. It belongs to the physiologic needs in Maslow’s Hierarchy of Needs.In terms of the resources, both the client and the nurse have the resources.

Risk for injury r/t the disorder of the inner ear

3 The nature of the problem is low because it only requires minimal nursing support. It is considered as an potential factor. In terms of the resources, both the client and the nurse have the resources.

3.) What are the Nursing Interventions including the Health Teaching Plan

A.) Anxiety r/t the sudden episodes of complete disorientation that cause the person to fall secondary to vertigo

Interventions

•Provide accurate, consistent information regarding prognosis of the disease.Avoid arguing about patient’s perceptions of the situation

•Provide open environment in which the patient feels safe to discuss feelings or torefrain from talking

•Explain procedures, providing opportunity for questions and honest answer

•Maintain a calm manner while interacting with patient.

•Encourage patient to talk about anxious feelings and examine anxiety-provokingsituations if able to identify them. Assist patient in assessing the situation realistically and recognizing factors leading to the anxious feelings. Avoid falsereassurances

B.) Altered comfort r/t the sensation of spinning motion, fluctuating hearing loss, and

tinnitus

Interventions

•Provide a quiet and peaceful environment

•Provide time to rest and promote general comfort measures

•Stay with the patient who appeared anxious

•Assess the patient’s power needs or needs for control.

•Enhance the patient’s sense of autonomy. Do this by involving the patient indecision making, by giving information, and by enabling the patient to control theenvironment as appropriate. Encourage patient to identify strength

C.) Risk for injury r/t the disorder of the inner ear

Interventions

•Maintain a safe environment

•Assist with ambulation and self care activities as needed

•Keep side rails raised and bed in low position

•Encourage patient to drink prescribed fluid amounts. If oral fluids are tolerated,provide oral fluids patient prefers. Place at bedside within easy reach. Providefresh water and a straw. Be creative in selecting fluid sources (e.g., flavoredgelatin, frozen juice bars, sports drink).

•Assist patient if unable to feed self and encourage caregiver to assist withfeedings as appropriate

4.) After the intervention what are the intended outcome/s

5.) Pathophysiology