- Acute Confusion Related to Sensory deprivation and Shock as evidenced by
Cognitive dysfunction and Inability to initiate purposeful behavior - Deficient Knowledge Related to misinterpretation of causes of vertigo as evidenced by Inaccurate statements about vertigo and Nonadherence to rehabilitative exercises
- Risk for Falls Related to Dizziness and Impaired balance as evidenced by falls
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Hallucinations Paranoia Objective data: Fluctuation in cognition/consciousness Agitation/restlessness Inappropriate perceptions Lack of understanding or follow-through with tasks Tremors | Acute Confusion Related to Sensory deprivation and Shock as evidenced by Cognitive dysfunction and Inability to initiate purposeful behavior | Patient will display restoration of neurological functioning to baseline. Patient will demonstrate the ability to follow commands and appropriate motor behavior. | 1. Continuously monitor the patient’s behavior and cognition. A patient experiencing vertigo who develops additional neurological symptoms like confusion, vision changes, a headache, or gait changes may indicate a developing complication and must be addressed promptly. 2. Maintain safety. The patient who is confused and dizzy is at a very high risk for falls and injuries. The nurse should ensure their safety by utilizing a bed alarm, keeping the bed locked and in a low position, and keeping personal items within reach. 3. Reduce unnecessary environmental stimuli. Excessive and loud environmental stimuli can overwhelm a patient experiencing confusion. Reducing environmental stimuli promotes rest, reduces anxiety, and improves vertigo symptoms. 4. Take caution with medication administration. Common medications used to treat vertigo/dizziness, such as meclizine, may cause side effects of confusion or drowsiness in older adults. | Patient displayed restoration of neurological functioning to baseline. Patient demonstrated the ability to follow commands and appropriate motor behavior. |
| Subjective data: Verbalizes poor understanding Seeks additional information Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge Related to misinterpretation of causes of vertigo as evidenced by Inaccurate statements about vertigo and Nonadherence to rehabilitative exercises | Patient will verbalize understanding of the causes of vertigo and treatment options. Patient will demonstrate measures to help manage vertigo and its related symptoms. | 1. Educate on canalith repositioning procedures for BPPV. BPPV is triggered by changes in head position. Specialists can perform maneuvers of the head and neck to reduce dizziness. 2. Educate the patient about the medications for vertigo. Medications for vertigo include antihistamines and anticholinergics, as they can relieve vertigo, light-headedness, nausea, and dizziness. 3. Advise the patient to avoid stressful situations. Vertigo can be triggered by stress. Anxiety can make the associated symptoms of vertigo worse. 4. Educate on surgical options. Surgical options include draining fluid in the inner ear, removing the part of the ear causing vertigo (which will also cause complete hearing loss), and cutting the vestibular nerve | Patient verbalized understanding of the causes of vertigo and treatment options. Patient demonstrated measures to help manage vertigo and its related symptoms. |
| Subjective data: Verbalizes fear of fall Objective data: -Dizziness -Impaired balance | Risk for Falls Related to Dizziness and Impaired balance as evidenced by falls | Patient will verbalize understanding of the condition and its safety issues. Patient will demonstrate interventions that reduce the risk of falls. | 1. Use extra time to stand. Encourage the patient to move and stand slowly to allow their equilibrium to adjust. 2. Sit down during a vertigo attack. If spinning or dizziness occurs, sit down to prevent losing balance and falling. 3. Squat to pick something up. Bending over at the hip with the head down can trigger vertigo. Instruct the patient to squat instead of bending over when picking something up. 4. Encourage the use of ambulation devices. The patient may need to use a walker or wheelchair if vertigo occurs suddenly or frequently to support their balance. | Patient verbalized understanding of the condition and its safety issues. Patient demonstrated interventions that reduce the risk of falls. |