Renea_Renea

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.

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.

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