Subjective assessment • • • • • Difficulty hearing Tinnitus Roaring sounds Feeling of pressure or fullness in the ear Nausea

Objective assessment

• • • • • • • •

Diaphoretic Emesis X 2 Emesis with gastric juices Disequilibrium Sensorineural hearing loss Elevated Sodium Lives alones Orders meals on wheels

Diagnostic testing • Rinne and Webster testing

non threatening manner using short and simple words with an appropriate volume • Encourage patient to continue to make his own decisions daily Rationales • • Patient will not feel threatened Patient will maintain a sense of dignity Evaluations Goals met patient was able to continue ordering his meals.• Sodium 160 Nursing Diagnosis Communication related to Sensorineural hearing loss Desired Outcomes: Mr. Clark will maintain optimal functioning within limits of hearing impairments as evidence by: • • Ability to communicate effectively and respond appropriately Patient is able to maintain independence in ordering his meals x 7 days Interventions • Approach patient in a calm. Patient continue to communicate effectively no social isolation was experienced .

phone within reach Rationales • • To minimize risk of tripping.Nursing Diagnosis At risk for falls as evidence of disequilibrium Desired outcomes: Mr. consistent furniture arrangement with an obstructed walkway • Avoid doing things for client that client can do for self. • To minimize need to walk to get these items Evaluations • Goals was meet no injury occured . providing assistance as necessary • Keep necessay items including water. falls in the dark or injury from falling out of bed It is important for client to do as much as possible for self to maintain self-esteem and promote recovery. Clark will have no falls with injury as evidence by • • Patient does not fall and is free of injury caused by unsteady gait x 7 days Perform self care activities within level of own ability with out injury x 7 days Interventions: • Maintain a clutter free environment. snacks.

Nursing Diagnosis At risk for Fluid imbalance as evidence of elevated sodium levels and emesis Desired outcome • • Sodium results will be within 136-145 within 7 days Reduced/ Absence of emesis within 7 days Interventions: • • • Provide IV fluid per MD orders x 24 hrs Evaluate level of consciousness and muscular strength. movement Monitor lab levels Rationales • Replacement of total body water deficit will gradually restore sodium/water balance. • • Sodium imbalance may cause changes that vary from confusion and irritability. Evaluation . tone. Lab work needed to monitor if sodium level is being decrease and if the is any change metabolically with dehydration.

• • Goal was met patient sodium level was within normal range within 7 days There was no signs of emesis within 7 days Reference: All –in – one care planning resource. Mary Frances Moorhouse. Sweringgen Nursing care plans guidelines for individualizing client care across the life span 7th edition. Doerges. Alice C murr . pediatric. authors Marilyn E. Med.surgical. maternity and psychiatric nursing care plans author Pamela L.

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