Need help with NANDA Dx

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Specializes in L&D, Antepartum.

This is my last week of paperwork for school this semester. I'm so glad to be over with it. Anyway...

Here is my pt:

33yo woman who went in for a myrigotomy. She was vomiting a lot after surgery so they kept her overnight in M/S. I got her the next AM. She was fine, no N&V. She was getting ready to go home actually. She was walking the halls, alone, and she was slow, shuffling, resting frequently, swaying to the right. She said she was dizzy. Obviously it is because of the imbalance in her ear that she is walking unbalanced. SO.. what should my dx be?

Risk for Injury

Risk for Falls

Impaired walking

Delayed surgical recovery

Those are in order of what I think it should be. So, any help?

Thanks!!

- N

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Specializes in med/surg, telemetry, IV therapy, mgmt.

eandgsma. . .the first question i'm asking myself is why were these myringotomies done on a 33-year old woman? what's the underlying problem here? the only answer i can think of is otitis media and in a woman of this age, is it chronic? and why? misuse of q-tips comes to mind, but it could be other things. unlike children, who are the ones normally seen in the hospital having this kind of surgery, an adult can tell you what the symptoms of their ear infections are: earache, a sensation of stiffness and pain in the tissues of the jaw (the tissues around the ear) due to swelling, hearing loss, and purulent drainage. you've listed four symptoms that your patient has:

  • vomiting
  • slow, shuffling gait
  • swaying to the right
  • statement of being dizzy

in addition i think you should also review any other information you might have taken down from this patient's medical record that might relate to any underlying otitis media. it also seems that there might be some complications as the infection might have extended to the organs of balance. when you are writing a care plan you must take into account the symptoms that the patient is having. your mission then becomes one of finding nursing diagnoses with defining characteristics that match up to your patient's symptoms. then the foundation of your care plan is on it's way to being written.

the vomiting may be a symptom of the ear infection, the organs of the ear that have been affected by disease or a side effect of anesthesia. hard to know which is the underlying cause. however, since the patient underwent general anesthesia, this is still a general surgery patient and you need to keep the potential postoperative complications in mind:

  • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  • hypotension (shock, hemorrhage)
  • thrombophlebitis in the lower extremity
  • elevated or depressed temperature
  • any number of problems with the incision/wound/surgical site (dehiscence, evisceration, infection)
  • fluid and electrolyte imbalances
  • urinary retention
  • constipation
  • surgical pain
  • nausea/vomiting (paralytic ileus)

another question i have is were ventilating tubes also inserted along with the myringotomies? the patient's discharge teaching needs to include instruction on aftercare and expected events. if tubes were inserted the patient needs to know if they are to be removed in a follow-up appointment with the doctor or that they will fall out on their own. specific instructions that should be emphasized before discharge include such things as not increasing pressure in the head:

  • no strenuous activity
  • no rapid head movement
  • no bending over
  • no straining at a bm
  • no drinking through a straw
  • no forceful coughing
  • no nose blowing with the mouth closed
  • stay away from anyone who might have a cold or flu
  • keep any dressings clean and dry
  • keep the ears dry and clean of drainage
  • careful showering and no getting the ears wet (this applies to the washing of the hair)
  • take antibiotics as ordered
  • report any increase or change to appearance of drainage to the surgeon.

what about pain?

what about hearing problems? even with cotton balls in the ears to catch any drainage, hearing acuity is affected.

here is a list of possible nursing diagnoses that may be applicable to this patient. i feel that you need to address the problems with the ear and balance. these are very real problems the patient has now. i have also included some possible etiologies with some of the nursing diagnoses that may be present or fit with some of your patient's symptoms. however, i don't know all the information on this patient and am only postulating on what i know from experience. you should review or rethink the assessment data that you collected. i think there may be things you've overlooked and, perhaps, did not recognize as being important symptoms. that is why it is good to review the textbook symptoms of any medical disease they have. it helps to prod one's thinking about the observations they made during their physical assessment of the patient. my signature now includes a link to a critical thinking flow sheet that you can print out to help you in developing your nursing diagnoses related to specific medical diseases in developing this kind of information for care plans.

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What makes it so obvious that the swaying and dizziness is caused by the inner ear? Maybe its an effect of a med or something else completely. Is it safe to "assume" that her dizziness is caused by those things?

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Specializes in med/surg, telemetry, IV therapy, mgmt.
What makes it so obvious that the swaying and dizziness is caused by the inner ear? Maybe its an effect of a med or something else completely. Is it safe to "assume" that her dizziness is caused by those things?

Let me answer that.

It's obvious because it's a manifestation of the pathophysiology of middle and inner ear problems. If you read up on the pathophysiology of any of the diseases affecting the middle or inner ear you will find these symptoms listed.

You ask if it's safe to assume that the patient's dizziness is caused by medications or something else. Yes, it is part of your critical thinking process. But be prudent and efficient when you are doing your detective work. Your assessment information is like pieces of a puzzle that you want to include in the finished picture. Find ways to get them to fit first before going off on tangents. By reviewing the pathophysiology of middle and inner ear disease the patients symptoms would have fit right into place. Yes, I would also have checked to see if there were any drugs that might be contributing to this, but you'd have to look at the patient's history in taking the drug as well. I had also thought of the possibility that the patient might have had a previous stroke or had cardiac arrhythmias. However, it's best to work with the information that is known. This comes from data collected from the patient's chart and from the patient. I asked myself "why was this surgery done?" It had to be because of infection. The rings are almost exclusively inserted to allow pus to drain from the middle ear. The next step was to look at the signs and symptoms of inner ear infection and there they were, all the patient's symptoms. Didn't need to go any further. The point of the OPs post was looking for help with determining nursing diagnoses for this patient. She had the information, was just a little dizzy herself as far as where to go with it all (:lol2:), got her pointed in the right direction.

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