Thursday, January 12, 2012

Nursing Assessment for Dizziness Vertigo

Dizziness is classified into three categories-vertigo, syncope, and nonsyncope nonvertigo. Each category has a characteristic set of symptoms, all related to the sense of balance. In general, syncope is defined by a brief loss of consciousness (fainting) or by dimmed vision and feeling uncoordinated, confused, and lightheaded. Many people experience a sensation like syncope when they stand up too fast. Vertigo is the feeling that either the individual or the surroundings are spinning. This sensation is like being on a spinning amusement park ride. Individuals with nonsyncope nonvertigo dizziness feel as though they cannot keep their balance. This feeling may become worse with movement.

Nursing Assessment Nursing Care Plan for Dizziness Vertigo

1. Activity / Rest
  • Fatigue, weakness, malaise
  • limitation of motion
  • Eye strain, difficulty reading
  • Insomnia, waking in the morning, accompanied by headache.
  • Severe headaches when changes in posture, activity (work) or because the weather changes.

2. Circulation
  • History of hypertension
  • Vascular pulsations, eg temporal region.
  • Pale, flushed face.

3. Ego Integrity
  • Emotional stress factors / specific environment
  • Changes in disability, despair, hopelessness depression
  • Worries, anxiety, receptors for headaches.

4. Food and Fluid
  • Nausea / vomiting, anorexia (for pain)
  • Weight loss

5. Neuro-Sensory
  • Dizziness, disorientation (for headache)
  • History of seizures, head injury had just happened, trauma, stroke.
  • Aura; facial, olfactory, tinnitus.
  • Visual changes, sensitive to light / sound harsh, epistaxis.
  • Parastesia, progressive weakness / paralysis one side tempore
  • Changes in the patterns of speech / thought patterns
  • Easily aroused, sensitive to the stimulus.
  • Decreased deep tendon reflexes
  • Papilledema.

6. Pain / Comfort
  • Characteristics of pain depends on the type of headache, eg migraine, muscle tension, cluster, brain tumors, post-traumatic, sinusitis.
  • Pain, redness, pale in the face.
  • The focus narrows
  • Focus on own
  • Emotional responses / behaviors like crying undirected, anxiety.
  • The muscles also tighten the neck area, frigidity vocals.

7. Security
  • History of allergy or allergic reactions
  • Fever (headache)
  • Gait disturbance, parastesia, paralysis
  • Purulent nasal drainage (sinus headache disorders).

8. Social Interaction
  • Changes in responsibility / role of social interaction associated with the disease.

9. Guidance / learning
  • History of hypertension, migraine, stroke, illness in family
  • Use of alcohol / other drugs, including caffeine. Oral contraceptives / hormone, menopause.

Nanda Nursing Diagnosis for Dizziness Vertigo

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