Help with Case Study

[Renea_Renea, BSN, MSN, APRN, NP]

From reading my case study I came up w/ 2 nursing dx... Disturbed sensory perception R/T vertigo secondary to medication use AEB unstable gait/fall and Impaired tissue integrity R/T edema AEB facial contusion

I am having a hard time finding long and short term goals for each.

Ideas that I have came up with are: medication education r/t toxicity and education r/t avoid dizziness when changing positions

I have no idea what type of goals I should come up with for impaired tissue integrity

[dudette10, MSN, RN]

I'm a student, and I struggle with careplans at times, too. But, I just want to say that your diagnoses don't seem exactly right to me, especially the first one.

I don't know what your case study says, but is the patient saying he/she feels dizzy? When someone is dizzy, the first thing I think of is risk for falls. I always thought impaired sensory perception was related to vision or hearing loss or distortion.

If the patient in your case study said something about dizziness, then that would be your subjective data, and the objective data would be unsteady gait and history of falls. The etiology would be side effects of medication, if you know that one of the medications can cause it, that is. Ear infections can also cause dizziness, so check out your case study for info pointing to that, too.

For your second diagnosis, edema would be the a/e/b statement, and the facial contusion would be the etiology. If the patient truly has a facial contusion, what about color and temperature of the site as more data for your diagnosis statement?

[REDDOG RN]

Could you give some details about the case study? That would make it alot easier in helping you.

[Renea_Renea, BSN, MSN, APRN, NP]

I am sorry that my information is vague. The pt doesn't have any hx of falls and pt stated she felt dizzy prior to her fall. That is why I went with Disturbed sensory perception instead of Risk for falls. I was under the assumption medication caused her dizziness.

If I am looking/searching in the wrong direction, I could change it if that is best.

So this is what I came up with Help Please!!!

Nursing Diagnosis: Disturbed sensory perception R/T vertigo secondary to medication use AEB unstable gait/fall

Long - term goal:

Short - term goal: Reduce dizziness when mobile by taking intermittent pulses between position changes. Patient education will occur regarding medication use along with signs of toxicity. Patient will remain dizzy free and free from falls while hospitalize under staff care. Prior to discharge patient will verbalize signs of toxicity regarding medication prescribed. Patient will also be given written directions on what to do when signs and symptoms of toxicity occur.

Nursing Diagnosis: Impaired tissue integrity R/T edema AEB facial bruising and lacerations

Long - term goal:

Short - term goal: Swelling will decrease in size prior to discharge. Patient will use cold pack intermittently. Patient will report pain to a tolerable level within the next hour.

I am having trouble with long term goals? The long term goal must be something that can be accomplish once she is discharge and is at home.

Also please critique my nursing dx along with my short term goals.

[REDDOG RN]

Does the case study mention what type of medication she is on? Why was the patient hospitalized to begin with? How did she get the facial bruising and lacerations? Does patient have a hard time walking? Does she need assistance when walking or doing ADL's. Is she A&O x3? What is her medical history? Sorry that I'm asking all these questions, but many of these factor into the type of nursing diagnosis you may use. It'll also give me more of a clearer picture in terms of helping you.

[Renea_Renea, BSN, MSN, APRN, NP]

No the case study does not mention any specific medication she was taking before hospitalized, expect that she was taking antibiotics and antihypertensive meds.

I have a list of meds that she is currently taking while in the hosptial: Serrous Sulfate, Calciuim/ Vit D, Aspirin 81 mg, Lisinopril, Amlodipine Besylate, Neomycin.

The patient was hospitalized b/c she was trying to walk down stairs and became dizzy and fall. The pt doesn't have a hx of falls, and have a strong gait before this mishap. Pt doesn't use any assistive devices for walking, hearing or seeing. She is alert and oriented, I'm assuming. Doesn't have much medical hx besides the information that I already stated previously.